Healthcare Provider Details

I. General information

NPI: 1932100807
Provider Name (Legal Business Name): MICHAEL J SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 05/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 EL CAJON BLVD SUITE B
SAN DIEGO CA
92103-2591
US

IV. Provider business mailing address

PO BOX 638
SOLANA BEACH CA
92075-0638
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-3977
  • Fax: 619-692-4160
Mailing address:
  • Phone: 619-692-3977
  • Fax: 619-692-4160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberG66543
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG66543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: