1285813360 NPI number — MATTHEW R SULLIVAN OD PC

Table of content: (NPI 1285813360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285813360 NPI number — MATTHEW R SULLIVAN OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATTHEW R SULLIVAN OD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PREMIER EYE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285813360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
980 WILLOW CREEK ROAD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-778-3937
Provider Business Mailing Address Fax Number:
928-778-3939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
980 WILLOW CREEK ROAD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-778-3937
Provider Business Practice Location Address Fax Number:
928-778-3939
Provider Enumeration Date:
10/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
HOLMES
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
928-778-3937

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1102 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4244670001 . This is a "DMERC" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 578966 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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