Healthcare Provider Details

I. General information

NPI: 1386621779
Provider Name (Legal Business Name): RICHARD R SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 TORRANCE BLVD
TORRANCE CA
90503
US

IV. Provider business mailing address

DEPT LA 21552
PASADENA CA
91185-1552
US

V. Phone/Fax

Practice location:
  • Phone: 310-303-5750
  • Fax:
Mailing address:
  • Phone: 949-263-8600
  • Fax: 562-590-7452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG57936
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberG57936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: