Provider Demographics
NPI:1376613737
Name:SULLIVAN, GERALD EUGENE (GERALD SULLIVAN)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:EUGENE
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:GERALD SULLIVAN
Other - Prefix:DR
Other - First Name:GERALD
Other - Middle Name:EUGENE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:730 FAIRVIEW AVE
Mailing Address - Street 2:SUITE B1
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2367
Mailing Address - Country:US
Mailing Address - Phone:270-781-3321
Mailing Address - Fax:270-781-9121
Practice Address - Street 1:730 FAIRVIEW AVE
Practice Address - Street 2:SUITE B1
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2367
Practice Address - Country:US
Practice Address - Phone:270-781-3321
Practice Address - Fax:270-781-9121
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15078207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology