1104994987 NPI number — JOSEPH B. SULLIVAN, O.D. PA

Table of content: (NPI 1104994987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104994987 NPI number — JOSEPH B. SULLIVAN, O.D. PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSEPH B. SULLIVAN, O.D. PA
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:
Provider Other Organization Name Type Code:
6
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:
1104994987
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8118 E DOUGLAS AVE
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67206-2364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-683-8204
Provider Business Mailing Address Fax Number:
316-683-8204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8118 E DOUGLAS AVE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67206-2364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-683-8204
Provider Business Practice Location Address Fax Number:
316-683-8204
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
316-683-8204

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1091-3 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100089620C , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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