Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 3491 T1509 | OH |
NPI | 1013051358 |
---|---|
Provider Name | Dr. Susan Ross |
First Address | Mayfield Heights, OH 44124-4411 |
Second Address | Lakewood, OH 44107-3110 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/02/2007 |
Last Update Date | 20/04/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U76945 | (02) | OH |