Provider Demographics
NPI:1093400269
Name:SULLIVAN, MARK F (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:F
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 1:1053 MERRICK DR APT 141
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-3735
Mailing Address - Country:US
Mailing Address - Phone:540-406-0076
Mailing Address - Fax:
Practice Address - Street 1:4414 SHELBYVILLE RD STE 204
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5328
Practice Address - Country:US
Practice Address - Phone:504-894-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2311DT152WX0102X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152W00000XEye and Vision Services ProvidersOptometrist