Provider Demographics
NPI:1326154477
Name:SULLIVAN, KERRY P (OD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:P
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:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NC
Mailing Address - Zip Code:27983-0160
Mailing Address - Country:US
Mailing Address - Phone:252-794-3381
Mailing Address - Fax:
Practice Address - Street 1:106 N KING ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-6863
Practice Address - Country:US
Practice Address - Phone:252-794-3381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1268152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC246530Medicare ID - Type Unspecified
NC0153920001Medicare NSC
T65055Medicare UPIN