Provider Demographics
NPI:1366613010
Name:GILL, SUSIE (OD)
Entity type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:GILL
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 1:2111 E HIGHLAND AVE STE B240
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4741
Mailing Address - Country:US
Mailing Address - Phone:480-994-5012
Mailing Address - Fax:480-990-7364
Practice Address - Street 1:7245 E OSBORN RD STE 4
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6443
Practice Address - Country:US
Practice Address - Phone:480-994-5012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1664152W00000X
MA4609152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ711616Medicaid