Provider Demographics
NPI:1588918676
Name:DIDEHBAN, SUE SOROOR
Entity type:Individual
Prefix:MRS
First Name:SUE
Middle Name:SOROOR
Last Name:DIDEHBAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7447 W EMERALD ST STE 105
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5003
Mailing Address - Country:US
Mailing Address - Phone:208-322-1642
Mailing Address - Fax:208-378-4179
Practice Address - Street 1:7447 W EMERALD ST STE 105
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5003
Practice Address - Country:US
Practice Address - Phone:208-322-1642
Practice Address - Fax:208-378-4179
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID000666777S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician