Provider Demographics
NPI:1285813360
Name:MATTHEW R SULLIVAN OD PC
Entity type:Organization
Organization Name:MATTHEW R SULLIVAN OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:HOLMES
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-778-3937
Mailing Address - Street 1:980 WILLOW CREEK ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301
Mailing Address - Country:US
Mailing Address - Phone:928-778-3937
Mailing Address - Fax:928-778-3939
Practice Address - Street 1:980 WILLOW CREEK ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-778-3937
Practice Address - Fax:928-778-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1102152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4244670001OtherDMERC
AZ578966Medicaid
Z64294Medicare UPIN
AZ578966Medicaid
AZ64294Medicare PIN