Provider Demographics
NPI:1982768651
Name:GARRETT F. SULLIVAN OD
Entity Type:Organization
Organization Name:GARRETT F. SULLIVAN OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARRETT
Authorized Official - Middle Name:F
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:978-562-7976
Mailing Address - Street 1:34 POPE ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:MA
Mailing Address - Zip Code:01749-2182
Mailing Address - Country:US
Mailing Address - Phone:978-562-7976
Mailing Address - Fax:978-562-4807
Practice Address - Street 1:34 POPE ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:MA
Practice Address - Zip Code:01749-2182
Practice Address - Country:US
Practice Address - Phone:978-562-7976
Practice Address - Fax:978-562-4807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2233152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W20431OtherBLUECROSS BLUESHIELD
MA9764054Medicaid
W20431OtherBLUECROSS BLUESHIELD
MAVX3082Medicare PIN