Provider Demographics
NPI:1750318580
Name:DIEDERICH, SUSAN N (OD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:N
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:N
Other - Last Name:BRAHM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:7511 HARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2606
Mailing Address - Country:US
Mailing Address - Phone:414-453-1300
Mailing Address - Fax:414-453-1330
Practice Address - Street 1:7511 HARWOOD AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2606
Practice Address - Country:US
Practice Address - Phone:414-453-1300
Practice Address - Fax:414-453-1330
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2981-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38624700Medicaid
WI2981OtherEYEMED VISION NO.
WI2981OtherEYEMED VISION NO.
WIV01392Medicare UPIN