1508894007 NPI number — DR. SUSAN M DINI OD

Table of content: DR. SUSAN M DINI OD (NPI 1508894007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508894007 NPI number — DR. SUSAN M DINI OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DINI
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508894007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9040A JACKSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98431-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-968-3760
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2939 BENJAMIN CT SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98501-4807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-970-1018
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3352 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2021046 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5001612 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2046506 . This is a "GROUP MEDICAID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3108383 . This is a "AETNA HMO" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 912113458 . This is a "PREMERA PNWEYECARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1199DI . This is a "REGENCE BS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2033124 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".