Provider Demographics
NPI:1396741161
Name:SULLINS, STUART (OD)
Entity type:Individual
Prefix:
First Name:STUART
Middle Name:
Last Name:SULLINS
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 1:517 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-3621
Mailing Address - Country:US
Mailing Address - Phone:423-745-4910
Mailing Address - Fax:423-742-2230
Practice Address - Street 1:517 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3621
Practice Address - Country:US
Practice Address - Phone:423-745-4910
Practice Address - Fax:423-742-2230
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000001899152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3101119Medicaid
TN3101119Medicaid
TNU66682Medicare UPIN