Provider Demographics
NPI:1346215134
Name:HALL, SUZANNE R (OD)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:R
Last Name:HALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SUZANNE
Other - Middle Name:R
Other - Last Name:DETERVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:30 W 60TH ST
Mailing Address - Street 2:SUITE 1Y
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-7902
Mailing Address - Country:US
Mailing Address - Phone:212-262-5177
Mailing Address - Fax:
Practice Address - Street 1:30 W 60TH ST
Practice Address - Street 2:SUITE 1Y
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7902
Practice Address - Country:US
Practice Address - Phone:212-262-5177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007085-1152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAV06948Medicare UPIN
VA008845P76Medicare ID - Type UnspecifiedMEDICARE