1255371407 NPI number — DR. SUSAN GROMACKI LATHROP O.D.

Table of content: DR. SUSAN GROMACKI LATHROP O.D. (NPI 1255371407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255371407 NPI number — DR. SUSAN GROMACKI LATHROP O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LATHROP
Provider First Name:
SUSAN
Provider Middle Name:
GROMACKI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1255371407
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4868 GREEN BRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21036-1211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-531-6967
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8115 MAPLE LAWN BLVD.
Provider Second Line Business Practice Location Address:
SUITE 135
Provider Business Practice Location Address City Name:
FULTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20759-2681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-490-3036
Provider Business Practice Location Address Fax Number:
443-288-4694
Provider Enumeration Date:
06/07/2006

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:  4901003970 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: TA2282 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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