Provider Demographics
NPI:1811972680
Name:KOSTKA-SUVELZA, MARCIA (OD)
Entity type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:
Last Name:KOSTKA-SUVELZA
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 1:604 I ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5530
Mailing Address - Country:US
Mailing Address - Phone:219-326-8855
Mailing Address - Fax:219-326-8835
Practice Address - Street 1:604 I ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5530
Practice Address - Country:US
Practice Address - Phone:219-326-8855
Practice Address - Fax:219-326-8835
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200108470AMedicaid
IN200108470AMedicaid
238260AMedicare ID - Type Unspecified