Provider Demographics
NPI:1992802656
Name:SULLIVAN, JAMES CHESTER (OD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:CHESTER
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:J.C.
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1906 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-3393
Mailing Address - Country:US
Mailing Address - Phone:509-547-8409
Mailing Address - Fax:
Practice Address - Street 1:1906 N 20TH AVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-3393
Practice Address - Country:US
Practice Address - Phone:509-547-8409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00004061152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00425941OtherRAILROAD MEDICARE
WA2033561Medicaid
WA0222797OtherDEPT OF LABOR & INDUSTRY
WA8866495Medicare PIN