Provider Demographics
NPI:1750320404
Name:SULLIVAN, DANIEL JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOSEPH
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 1:1180 BLOWING ROCK RD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-4883
Mailing Address - Country:US
Mailing Address - Phone:828-264-2020
Mailing Address - Fax:828-264-8918
Practice Address - Street 1:1180 BLOWING ROCK RD
Practice Address - Street 2:SUITE 1A
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4883
Practice Address - Country:US
Practice Address - Phone:828-264-2020
Practice Address - Fax:828-264-8918
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1778152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0919IOtherBCBSNC
NC790919IMedicaid
NC790919IMedicaid
NCU78194Medicare UPIN