Provider Demographics
NPI:1215160064
Name:OM, SUSAN (OD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:OM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:YOUN JOO
Other - Middle Name:
Other - Last Name:OM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5639 202ND ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1628
Mailing Address - Country:US
Mailing Address - Phone:917-817-2270
Mailing Address - Fax:
Practice Address - Street 1:13687 37TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4110
Practice Address - Country:US
Practice Address - Phone:917-817-2270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007399-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist