Basic Information
| Provider Information | |||||||||
| NPI: | 1154686889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LY | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11444 KENTSHIRE WAY | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220307443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033388444 | ||||||||
| FaxNumber: | 7038170748 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 OLD GALLOWS RD | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 7039910514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2012 | ||||||||
| LastUpdateDate: | 08/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA2308 | MD | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 0618002157 | VA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.