Provider Demographics
NPI:1275696056
Name:SULLIVAN, PRESTON (MD)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 OLYMPIC DR STE 110
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1778
Mailing Address - Country:US
Mailing Address - Phone:253-432-3238
Mailing Address - Fax:253-509-0217
Practice Address - Street 1:5201 OLYMPIC DR STE 110
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1778
Practice Address - Country:US
Practice Address - Phone:253-432-3238
Practice Address - Fax:253-509-0217
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044121207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8404758Medicaid
WA8404758Medicaid
WAH65294Medicare UPIN