Provider Demographics
NPI:1619262029
Name:DR JAMES B SULLIVAN
Entity Type:Organization
Organization Name:DR JAMES B SULLIVAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-265-7417
Mailing Address - Street 1:59 ELM STREET PO BOX 5103
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-5103
Mailing Address - Country:US
Mailing Address - Phone:315-265-7417
Mailing Address - Fax:315-265-7417
Practice Address - Street 1:59 ELM STREET
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-5103
Practice Address - Country:US
Practice Address - Phone:315-265-7417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT-003488152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU61432Medicare UPIN
NY5590310001Medicare NSC