Provider Demographics
NPI:1427065754
Name:FISHER, SUSAN (OD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FISHER
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 1:1600 STEWART AVE
Mailing Address - Street 2:STE 108
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-6611
Mailing Address - Country:US
Mailing Address - Phone:516-783-6460
Mailing Address - Fax:
Practice Address - Street 1:1285 OWEN PL
Practice Address - Street 2:
Practice Address - City:NORTH BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-2118
Practice Address - Country:US
Practice Address - Phone:516-783-6460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0004117152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11-2879341OtherTPI
410044468OtherRRPRV
NYOV004117Medicaid
T49056Medicare UPIN
NYOV004117Medicaid