Provider Demographics
NPI:1740620673
Name:SULLIVAN, ANNAMARIE (OD)
Entity type:Individual
Prefix:
First Name:ANNAMARIE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-2847
Mailing Address - Country:US
Mailing Address - Phone:904-559-9025
Mailing Address - Fax:904-861-3899
Practice Address - Street 1:611 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-2847
Practice Address - Country:US
Practice Address - Phone:904-559-9025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5170152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSIOKGOtherBCBS
FLOPC5170OtherFLORIDA DOH OPTOMETRY LICENSE