Provider Demographics
NPI:1518410133
Name:SULLIVAN, TARA L (OD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 LISBON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7418
Mailing Address - Country:US
Mailing Address - Phone:207-786-2500
Mailing Address - Fax:207-786-2503
Practice Address - Street 1:245 CENTER ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-6169
Practice Address - Country:US
Practice Address - Phone:207-786-2500
Practice Address - Fax:207-786-2503
Is Sole Proprietor?:No
Enumeration Date:2016-07-31
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5072152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist