Healthcare Provider Details

I. General information

NPI: 1598844730
Provider Name (Legal Business Name): MARY VERONICA SULLIVAN OPTICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3768 SENECA STREET
WEST SENECA NY
14224
US

IV. Provider business mailing address

3768 SENECA STREET
WEST SENECA NY
14224
US

V. Phone/Fax

Practice location:
  • Phone: 716-674-8300
  • Fax: 716-674-8302
Mailing address:
  • Phone: 716-674-8300
  • Fax: 716-674-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number0038461
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: