Provider Demographics
NPI:1871598219
Name:SUSI, J RICHARD (DO)
Entity type:Individual
Prefix:
First Name:J
Middle Name:RICHARD
Last Name:SUSI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7326 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-6055
Mailing Address - Country:US
Mailing Address - Phone:407-380-2020
Mailing Address - Fax:407-381-8112
Practice Address - Street 1:7326 LAKE UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-6055
Practice Address - Country:US
Practice Address - Phone:407-380-2020
Practice Address - Fax:407-381-8112
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4893207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078374900Medicaid
FL82724Medicare ID - Type Unspecified
FLD60714Medicare UPIN