1629106729 NPI number — MRS. SUSAN EVANS OD

Table of content: MRS. SUSAN EVANS OD (NPI 1629106729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629106729 NPI number — MRS. SUSAN EVANS OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
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:
1629106729
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8614 WESTWOOD CENTER DR FL 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22182-2442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-847-8899
Provider Business Mailing Address Fax Number:
571-223-6780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
93 EVERGREEN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH WINDSOR
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06074-6975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-826-4460
Provider Business Practice Location Address Fax Number:
860-826-4436
Provider Enumeration Date:
03/01/2007

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:  002478 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004188847 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1255448155 . This is a "GHMC GROUP MEDICAID ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: CT2478 . This is a "EYE MED VISION CARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 090002478CT04 . This is a "BCBS & BCFP PROVIDER ID" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 102478 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1255448155 . This is a "GHMC GROUP NPI" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V9149 . This is a "HEALTH NET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 932470 . This is a "BLOCK VISION" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com