Provider Demographics
NPI:1134554496
Name:SUSKOVICH, NIKKI ROBIN (OD)
Entity type:Individual
Prefix:DR
First Name:NIKKI
Middle Name:ROBIN
Last Name:SUSKOVICH
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 1:8135 BOWLINE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-8417
Mailing Address - Country:US
Mailing Address - Phone:317-826-4173
Mailing Address - Fax:
Practice Address - Street 1:10735 PENDLETON PIKE
Practice Address - Street 2:C/O WAL-MART VISION CENTER
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236
Practice Address - Country:US
Practice Address - Phone:317-823-1886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002711152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU60367Medicare UPIN
204150Medicare PIN