Provider Demographics
NPI:1023018041
Name:SULLIVAN, ROBERT LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEE
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 1:2325 ABERDEEN BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0614
Mailing Address - Country:US
Mailing Address - Phone:704-853-3937
Mailing Address - Fax:704-853-0840
Practice Address - Street 1:2325 ABERDEEN BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0614
Practice Address - Country:US
Practice Address - Phone:704-853-3937
Practice Address - Fax:704-853-0840
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1401152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890904MMedicaid
NC0904MOtherBLUE CROSS OF N C
NC62842OtherMEDCOST
NC10930OtherPARTNERS MEDICARE CHOICE
NC10930OtherPARTNERS MEDICARE CHOICE
NC890904MMedicaid