Healthcare Provider Details

I. General information

NPI: 1396741161
Provider Name (Legal Business Name): STUART SULLINS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 N JACKSON ST
ATHENS TN
37303-3621
US

IV. Provider business mailing address

517 N JACKSON ST
ATHENS TN
37303-3621
US

V. Phone/Fax

Practice location:
  • Phone: 423-745-4910
  • Fax: 423-742-2230
Mailing address:
  • Phone: 423-745-4910
  • Fax: 423-742-2230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000001899
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: