Provider Demographics
NPI:1467670398
Name:SULT, TIMOTHY MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:SULT
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 1:12828 LINDLEY DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8776
Mailing Address - Country:US
Mailing Address - Phone:919-841-0404
Mailing Address - Fax:
Practice Address - Street 1:6120 GLENWOOD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-2614
Practice Address - Country:US
Practice Address - Phone:919-571-1366
Practice Address - Fax:919-571-7146
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1309152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909885Medicaid
NC09885OtherBLUE CROSS BLUE SHIELD
NC2256770OtherUNITED HEALTH CARE
NC09885OtherBLUE CROSS BLUE SHIELD
NC2256770OtherUNITED HEALTH CARE