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General NPI Number Information
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NPI Number | 1285813360
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Entity Type | Organization
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Legal Business Name | MATTHEW R SULLIVAN OD PC
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Dates
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Enumeration Date | 10/25/2007
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Last Update Date | 03/30/2021
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Provider Practice Location Address
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Address Line | 980 WILLOW CREEK ROAD SUITE 202
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City | PRESCOTT
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State | AZ
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Zip | 86301
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Country | US
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Telephone | 928-778-3937
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Fax | 928-778-3939
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Provider Business Mailing Address
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Address Line | 980 WILLOW CREEK ROAD SUITE 202
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City | PRESCOTT
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State | AZ
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Zip | 86301
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Country | US
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Telephone | 928-778-3937
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Fax | 928-778-3939
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | TRACY HOLMES SULLIVAN
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Credential |
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Telephone | 928-778-3937
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1102
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License Number State | AZ
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