Provider Demographics
NPI:1871519710
Name:MENCARINI, SUSAN DIANE (OD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:MENCARINI
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 1:145 N CLOVIS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0361
Mailing Address - Country:US
Mailing Address - Phone:559-298-2120
Mailing Address - Fax:559-299-3741
Practice Address - Street 1:145 N CLOVIS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0361
Practice Address - Country:US
Practice Address - Phone:559-298-2120
Practice Address - Fax:559-299-3741
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9050T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0090500Medicare ID - Type Unspecified
U11217Medicare UPIN