Healthcare Provider Details

I. General information

NPI: 1588893564
Provider Name (Legal Business Name): MARY LORAINE SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 W MAIN ST # 240
EL CAJON CA
92020-3315
US

IV. Provider business mailing address

133 W MAIN ST # 240
EL CAJON CA
92020-3315
US

V. Phone/Fax

Practice location:
  • Phone: 619-401-0404
  • Fax:
Mailing address:
  • Phone: 619-401-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number132556
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: