Provider Demographics
NPI:1548310212
Name:FONG, SUSAN HSIN MEI (OD)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:HSIN MEI
Last Name:FONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:FONG BOARMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10400 E ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80247-5104
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001026152W00000X
MDTA1598152W00000X
COOPT.0002518152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO88005038Medicaid
CO018714OtherKAISER COMMERCIAL NUMBER
COCO304249Medicare PIN
CO88005038Medicaid