Provider Demographics
NPI:1154385045
Name:GODZAC, SUSAN JEAN (OD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:GODZAC
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:PA
Mailing Address - Zip Code:16417-1615
Mailing Address - Country:US
Mailing Address - Phone:814-774-2017
Mailing Address - Fax:814-774-8558
Practice Address - Street 1:229 MAIN ST W
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:PA
Practice Address - Zip Code:16417-1615
Practice Address - Country:US
Practice Address - Phone:814-774-2017
Practice Address - Fax:814-774-8558
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE005361T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist