Provider Demographics
NPI:1548314750
Name:SUTIJONO, LIEZL R (OD)
Entity type:Individual
Prefix:DR
First Name:LIEZL
Middle Name:R
Last Name:SUTIJONO
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 1:6562 WHITBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-4553
Mailing Address - Country:US
Mailing Address - Phone:650-892-4809
Mailing Address - Fax:
Practice Address - Street 1:529 HAYES ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-4213
Practice Address - Country:US
Practice Address - Phone:415-553-6166
Practice Address - Fax:415-553-6168
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007100152W00000X
CA13658152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOP2839OtherEYEMED
NY02848199Medicaid