Provider Demographics
NPI:1104994987
Name:JOSEPH B. SULLIVAN, O.D. PA
Entity type:Organization
Organization Name:JOSEPH B. SULLIVAN, O.D. PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:B
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:316-683-8204
Mailing Address - Street 1:8118 E DOUGLAS AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2364
Mailing Address - Country:US
Mailing Address - Phone:316-683-8204
Mailing Address - Fax:316-683-8204
Practice Address - Street 1:8118 E DOUGLAS AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2364
Practice Address - Country:US
Practice Address - Phone:316-683-8204
Practice Address - Fax:316-683-8204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1091-3152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100089620CMedicaid
KSU71963Medicare UPIN
KS4379870001Medicare NSC