Basic Information
| Provider Information | |||||||||
| NPI: | 1497752356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAYNE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 VONDERBURG DR | ||||||||
| Address2: | STE 101 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136811122 | ||||||||
| FaxNumber: | 8136844924 | ||||||||
| Practice Location | |||||||||
| Address1: | 4051 UPPER CREEK DR | ||||||||
| Address2: | STE 107 | ||||||||
| City: | SUN CITY CENTER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335736825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136348877 | ||||||||
| FaxNumber: | 8136342266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2005 | ||||||||
| LastUpdateDate: | 07/24/2013 | ||||||||
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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 | OPC3517 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 20976 | 01 | FL | BCBS FLORIDA | OTHER | 2508546 | 01 | FL | AENTA | OTHER | 7286206 | 01 | FL | AETNA | OTHER | 620559300 | 05 | FL | MEDICAID | 6599633 | 01 | NY | GHI | OTHER |