Individual
DR. MATTHEW RYAN SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
980 WILLOW CREEK ROAD, SUITE 202, PRESCOTT, AZ 86301-1610
(928) 778-3937
(928) 778-3939
Mailing address
980 WILLOW CREEK ROAD, SUITE 202, PRESCOTT, AZ 86301-1610
(928) 778-3937
(928) 778-3939
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
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