Provider Demographics
NPI:1598844730
Name:SULLIVAN, MARY VERONICA (OPTICIAN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:VERONICA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3768 SENECA STREET
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224
Mailing Address - Country:US
Mailing Address - Phone:716-674-8300
Mailing Address - Fax:716-674-8302
Practice Address - Street 1:3768 SENECA STREET
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224
Practice Address - Country:US
Practice Address - Phone:716-674-8300
Practice Address - Fax:716-674-8302
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0038461156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNY3846OtherEYEMED
NY0269410001Medicare ID - Type Unspecified