Provider Demographics
NPI:1053311472
Name:SULLIVAN, MATTHEW RYAN (OD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RYAN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 WILLOW CREEK ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1610
Mailing Address - Country:US
Mailing Address - Phone:928-778-3937
Mailing Address - Fax:928-778-3939
Practice Address - Street 1:980 WILLOW CREEK ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1610
Practice Address - Country:US
Practice Address - Phone:928-778-3937
Practice Address - Fax:928-778-3939
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1102152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1053311472OtherINDIVIDUAL NPI
AZ410045761OtherRAILROAD
AZ1285813360OtherGROUP NPI
AZ64294OtherMEDICARE GROUP NUMBER
AZ1102OtherSTATE LICENSE
AZ620353Medicaid
AZ620353Medicaid
Z64295Medicare UPIN
AZU82033Medicare UPIN