Provider Demographics
NPI:1700168333
Name:SULLIVAN, MICHAEL JAMES (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:125 MARTIN AVE. WEST
Mailing Address - Street 2:
Mailing Address - City:WINNIPEG
Mailing Address - State:MANITOBA
Mailing Address - Zip Code:R2L 0B3
Mailing Address - Country:CA
Mailing Address - Phone:204-663-8744
Mailing Address - Fax:204-663-6412
Practice Address - Street 1:59 ELM ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1808
Practice Address - Country:US
Practice Address - Phone:315-265-7417
Practice Address - Fax:315-265-7417
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007119-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist