Provider Demographics
NPI:1871763722
Name:PAUL J SUSCAVAGE OD
Entity type:Organization
Organization Name:PAUL J SUSCAVAGE OD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-368-4660
Mailing Address - Street 1:850 S VALLEY FORGE RD
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-4261
Mailing Address - Country:US
Mailing Address - Phone:215-368-4660
Mailing Address - Fax:215-368-1776
Practice Address - Street 1:850 S VALLEY FORGE RD
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-4261
Practice Address - Country:US
Practice Address - Phone:215-368-4660
Practice Address - Fax:215-368-1776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OEG-001503152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU01335Medicare UPIN
PA024554Medicare PIN