Healthcare Provider Details

I. General information

NPI: 1992716997
Provider Name (Legal Business Name): DREW SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 LINCOLN AVE
SAN JOSE CA
95126-3705
US

IV. Provider business mailing address

400 RACE ST
SAN JOSE CA
95126-3518
US

V. Phone/Fax

Practice location:
  • Phone: 408-278-3310
  • Fax: 408-278-3378
Mailing address:
  • Phone: 408-278-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG32274
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: