MEDICARE: DR. TIMOTHY MICHAEL SULT O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1309	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	09885	OTHER	NC	BLUE CROSS BLUE SHIELD
3	2256770	OTHER	NC	UNITED HEALTH CARE

General Provider Information

NPI Number	:	1467670398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY MICHAEL SULT O.D.

Provider Business Mailing Address
First Line	:	12828 LINDLEY DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27614-8776
Country	:	US
Telephone Number	:	919-841-0404
Fax Number	:

Provider Business Practice Location Address
First Line	:	6120 GLENWOOD AVE
Second Line	:	SUITE 104
City	:	RALEIGH
State	:	NC
Zip	:	27612-2614
Country	:	US
Telephone Number	:	919-571-1366
Fax Number	:	919-571-7146

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	09/12/2007

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