Provider Demographics
NPI:1316979487
Name:LIN, SUSAN T R (OD MS FAAO)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:T R
Last Name:LIN
Suffix:
Gender:F
Credentials:OD MS FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5802 COLLEGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618
Mailing Address - Country:US
Mailing Address - Phone:510-653-4242
Mailing Address - Fax:510-653-4275
Practice Address - Street 1:5802 COLLEGE AVENUE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618
Practice Address - Country:US
Practice Address - Phone:510-653-4242
Practice Address - Fax:510-653-4275
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9036T152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADO017AMedicare PIN