Provider Demographics
NPI:1043799844
Name:SULLIVAN, ROBERT D (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4801 S CLIFF AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6954
Mailing Address - Country:US
Mailing Address - Phone:816-478-1230
Mailing Address - Fax:816-350-4585
Practice Address - Street 1:2185 SOUTH MASON RD
Practice Address - Street 2:
Practice Address - City:TOWN & COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63131-1640
Practice Address - Country:US
Practice Address - Phone:314-821-5666
Practice Address - Fax:314-821-5322
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2018021513152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist