Provider Demographics
NPI:1104922079
Name:POE, SUSAN MAUREEN (OD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MAUREEN
Last Name:POE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5790 GYRFALCON PL
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-8938
Mailing Address - Country:US
Mailing Address - Phone:317-818-0609
Mailing Address - Fax:317-858-8403
Practice Address - Street 1:400 W NORTHFIELD DR
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-8122
Practice Address - Country:US
Practice Address - Phone:317-858-3083
Practice Address - Fax:317-858-8403
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002844B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN219410Medicare ID - Type Unspecified