Individual
DR. MATTHEW RYAN SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
1102
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1053311472
INDIVIDUAL NPI
AZ
01
—
1102
STATE LICENSE
AZ
01
—
1285813360
GROUP NPI
AZ
01
—
410045761
RAILROAD
AZ
05
—
620353
—
AZ
01
—
64294
MEDICARE GROUP NUMBER
AZ
Enumeration date
07/28/2005
Last updated
01/02/2014
Update your record
If you believe information in your NPPES record is inaccurate, or if you wish to update or deactivate your NPI, you can do so directly with CMS at https://nppes.cms.hhs.gov.
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