Provider Demographics
NPI:1184787988
Name:SULLIVAN, BRIAN W (OD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
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 1:215 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5030
Mailing Address - Country:US
Mailing Address - Phone:360-456-4800
Mailing Address - Fax:360-456-4812
Practice Address - Street 1:215 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5030
Practice Address - Country:US
Practice Address - Phone:360-456-4800
Practice Address - Fax:360-456-4812
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001680152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2011971Medicaid
WA013898Medicare UPIN