Basic Information
| Provider Information | |||||||||
| NPI: | 1083601280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4313 I 49 S SERVICE RD | ||||||||
| Address2: | |||||||||
| City: | OPELOUSAS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705700755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379422024 | ||||||||
| FaxNumber: | 3379486216 | ||||||||
| Practice Location | |||||||||
| Address1: | 4313 I 49 S SERVICE RD | ||||||||
| Address2: | |||||||||
| City: | OPELOUSAS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705700755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379422024 | ||||||||
| FaxNumber: | 3379486216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 993-236T | LA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1354945 | 05 | LA | MEDICAID |