Provider Demographics
NPI:1679618979
Name:FERENCE, SUSAN LEE (OD)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LEE
Last Name:FERENCE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1101 MELBOURNE RD
Mailing Address - Street 2:NORTH EAST MALL SUITE 5060
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-6205
Mailing Address - Country:US
Mailing Address - Phone:817-590-2022
Mailing Address - Fax:817-595-0366
Practice Address - Street 1:1101 MELBOURNE RD
Practice Address - Street 2:NORTH EAST MALL SUITE 5060
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-6205
Practice Address - Country:US
Practice Address - Phone:817-590-2022
Practice Address - Fax:817-595-0366
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX377OTG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU51969Medicare UPIN