Provider Demographics
NPI:1932187911
Name:MAYSTEAD, SUZANNE R (OD)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:R
Last Name:MAYSTEAD
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 1:1311 E BRIDGE STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875
Mailing Address - Country:US
Mailing Address - Phone:517-647-7515
Mailing Address - Fax:517-647-5445
Practice Address - Street 1:1311 E BRIDGE STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875
Practice Address - Country:US
Practice Address - Phone:517-647-7515
Practice Address - Fax:517-647-5445
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901SM002704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
200000002364OtherPHP
SM002704OtherBLUE CROSS
0157530001Medicare NSC
SM002704OtherBLUE CROSS
U31662Medicare UPIN