1497752356 NPI number — SUSAN H PAYNE O.D.

Table of content: SUSAN H PAYNE O.D. (NPI 1497752356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497752356 NPI number — SUSAN H PAYNE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAYNE
Provider First Name:
SUSAN
Provider Middle Name:
H
Provider Name Prefix Text:
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:
1497752356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
403 VONDERBURG DR
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33511-5982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-681-1122
Provider Business Mailing Address Fax Number:
813-684-4924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4051 UPPER CREEK DR
Provider Second Line Business Practice Location Address:
STE 107
Provider Business Practice Location Address City Name:
SUN CITY CENTER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33573-6825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-634-8877
Provider Business Practice Location Address Fax Number:
813-634-2266
Provider Enumeration Date:
07/06/2005

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:  OPC3517 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20976 . This is a "BCBS FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2508546 . This is a "AENTA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7286206 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 620559300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6599633 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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