Basic Information
| Provider Information | |||||||||
| NPI: | 1043799844 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4801 S CLIFF AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640556954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164781230 | ||||||||
| FaxNumber: | 8163504585 | ||||||||
| Practice Location | |||||||||
| Address1: | 2185 SOUTH MASON RD | ||||||||
| Address2: | |||||||||
| City: | TOWN & COUNTRY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631311640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148215666 | ||||||||
| FaxNumber: | 3148215322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2018 | ||||||||
| LastUpdateDate: | 11/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2018021513 | MO | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.