Provider Demographics
NPI:1053382077
Name:SUSCAVAGE, PAUL JACOB (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JACOB
Last Name:SUSCAVAGE
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:850 S VALLEY FORGE RD
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-4261
Practice Address - Country:US
Practice Address - Phone:215-368-4660
Practice Address - Fax:215-368-7176
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2022-03-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAOEG001503152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU01335Medicare UPIN