Provider Demographics
NPI:1619705951
Name:SULLIVAN, MITCHELL WILLIAM (OD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:WILLIAM
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 WINDERMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3538
Mailing Address - Country:US
Mailing Address - Phone:318-487-2020
Mailing Address - Fax:
Practice Address - Street 1:118 SOUTH DR
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5037
Practice Address - Country:US
Practice Address - Phone:318-352-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2035-981AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist