Provider Demographics
NPI:1609816271
Name:LEVIN, SUSAN DALE (OD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:DALE
Last Name:LEVIN
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 1:11 RUFFIAN DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-6662
Mailing Address - Country:US
Mailing Address - Phone:540-752-5043
Mailing Address - Fax:
Practice Address - Street 1:10001 SOUTHPOINT PKWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-2700
Practice Address - Country:US
Practice Address - Phone:540-834-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001045152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist