NPIMap

Organization Active NPI

Sullivan Eye Center, S.C.

  • Ophthalmology Physician
  • Appleton, WI
National Provider Identifier
1104919869
Registry record updated Sep 3, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
License
18799 Issued in WI
Legal business name
SULLIVAN EYE CENTER, S.C.
Practice address
1195 N Casaloma Dr
Appleton, WI 54913-9295
Phone
(920) 734-0400
Fax
(920) 734-9054
NPI assigned
Oct 2, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 3, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Robert D. Sullivan, M.D.
Title
President
Phone
(920) 734-0400

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 152W00000X 2483-035 WI
OptometristGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 152W00000X 2752-035 WI
OptometristGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 152W00000X 2681-035 WI
Ophthalmology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207W00000X 18799 WI Primary

Addresses

Primary practice location

1195 N Casaloma Dr
Appleton, WI 54913-9295

Mailing address

1195 N Casaloma Dr
Appleton, WI 54913-9295
Phone (920) 734-0400

Other identifiers 1

IdentifierTypeStateIssuer
38455900MedicaidWI

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159747200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1220400000000",
    "number": "1104919869",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1195 N CASALOMA DR",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "549139295",
            "telephone_number": "920-734-0400",
            "fax_number": "920-734-9054"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1195 N CASALOMA DR",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "549139295",
            "telephone_number": "920-734-0400",
            "fax_number": "920-734-9054"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SULLIVAN EYE CENTER, S.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-02",
        "last_updated": "2008-09-03",
        "status": "A",
        "authorized_official_last_name": "SULLIVAN",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "D.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "920-734-0400",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "WI",
            "license": "2483-035",
            "primary": false
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "WI",
            "license": "2752-035",
            "primary": false
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "WI",
            "license": "2681-035",
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Ophthalmology",
            "state": "WI",
            "license": "18799",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "38455900",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Appleton, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 3, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.