Healthcare Provider Details

I. General information

NPI: 1043799844
Provider Name (Legal Business Name): ROBERT D. SULLIVAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2185 SOUTH MASON RD
TOWN & COUNTRY MO
63131-1640
US

IV. Provider business mailing address

4801 S CLIFF AVE STE 100
INDEPENDENCE MO
64055-6954
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-5666
  • Fax: 314-821-5322
Mailing address:
  • Phone: 816-478-1230
  • Fax: 816-350-4585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2018021513
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: