Provider Demographics
NPI:1861500910
Name:SULLIVAN, VONDA JOLENE (OD)
Entity Type:Individual
Prefix:
First Name:VONDA
Middle Name:JOLENE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:VONDA
Other - Middle Name:JOLENE
Other - Last Name:CAPPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 1877
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50402-1877
Mailing Address - Country:US
Mailing Address - Phone:641-423-8861
Mailing Address - Fax:641-423-0727
Practice Address - Street 1:3121 4TH ST SW
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-1581
Practice Address - Country:US
Practice Address - Phone:641-423-8861
Practice Address - Fax:641-423-0727
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0484568Medicaid
U52407Medicare UPIN
IA0484568Medicaid