Provider Demographics
NPI:1053975763
Name:GRESHAM, SUSAN (OD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 N MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 COMMERCE RD
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-9032
Practice Address - Country:US
Practice Address - Phone:540-213-7720
Practice Address - Fax:540-213-9441
Is Sole Proprietor?:No
Enumeration Date:2019-04-28
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002780152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053975763Medicaid