Provider Demographics
NPI:1336199413
Name:SULLIVAN, REGINA MCCOLLUM (OD)
Entity type:Individual
Prefix:DR
First Name:REGINA
Middle Name:MCCOLLUM
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:REGINA
Other - Middle Name:LORRAINNE
Other - Last Name:MCCOLLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1560 INDIAN TRAIL RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-2666
Mailing Address - Country:US
Mailing Address - Phone:770-923-1011
Mailing Address - Fax:770-923-1041
Practice Address - Street 1:1560 INDIAN TRAIL RD
Practice Address - Street 2:SUITE 108
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-2613
Practice Address - Country:US
Practice Address - Phone:770-923-1011
Practice Address - Fax:770-923-1041
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA1647152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCFDQMedicare PIN
GAU79261Medicare UPIN