Provider Demographics
NPI:1871935122
Name:SULLIVAN, MARY C (O D)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:C
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:O D
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:C
Other - Last Name:DOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3737 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-1839
Mailing Address - Country:US
Mailing Address - Phone:479-659-1874
Mailing Address - Fax:
Practice Address - Street 1:2110 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3246
Practice Address - Country:US
Practice Address - Phone:479-636-8238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2688152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist