Healthcare Provider Details

I. General information

NPI: 1205825080
Provider Name (Legal Business Name): ERIN CLEARY SULLIVAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD OPHTHALMOLOGY CONSULTANTS LTD STE 5006B
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 5006B
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-5478
  • Fax: 314-569-0864
Mailing address:
  • Phone: 314-432-5478
  • Fax: 314-569-0864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2003015404
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: