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General NPI Number Information
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NPI Number | 1619262029
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Entity Type | Organization
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Legal Business Name | DR JAMES B SULLIVAN
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Dates
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Enumeration Date | 06/14/2011
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Last Update Date | 06/14/2011
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Provider Practice Location Address
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Address Line | 59 ELM STREET
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City | POTSDAM
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State | NY
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Zip | 13676-5103
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Country | US
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Telephone | 315-265-7417
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Fax |
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Provider Business Mailing Address
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Address Line | 59 ELM STREET PO BOX 5103
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City | POTSDAM
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State | NY
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Zip | 13676-5103
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Country | US
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Telephone | 315-265-7417
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Fax | 315-265-7417
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. JAMES B SULLIVAN
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Credential | OD
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Telephone | 315-265-7417
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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 | T-003488
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License Number State | NY
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