Healthcare Provider Details

I. General information

NPI: 1790641884
Provider Name (Legal Business Name): THEODORE K SULLIVAN, OD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2026
Last Update Date: 01/02/2026
Certification Date: 01/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERAMEC BLUFFS DR
BALLWIN MO
63021-3309
US

IV. Provider business mailing address

9015 EAGER RD APT 119
SAINT LOUIS MO
63144-1109
US

V. Phone/Fax

Practice location:
  • Phone: 636-861-0600
  • Fax:
Mailing address:
  • Phone: 314-478-3669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. THEODORE K SULLIVAN
Title or Position: OPTOMETRIST
Credential: OD
Phone: 314-478-3669