Healthcare Provider Details

I. General information

NPI: 1487700167
Provider Name (Legal Business Name): KATHRYN SULLIVAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MDG 101 BODIN CIRCLE
TRAVIS AFB CA
94535-1800
US

IV. Provider business mailing address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-7401
  • Fax:
Mailing address:
  • Phone: 720-220-4403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberV5135
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0101249048
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: