Healthcare Provider Details

I. General information

NPI: 1528387958
Provider Name (Legal Business Name): JONATHAN M SULLIVAN D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 FLORIDA PARK DR N
PALM COAST FL
32137-3866
US

IV. Provider business mailing address

1890 LPGA BLVD STE 230
DAYTONA BEACH FL
32117-7131
US

V. Phone/Fax

Practice location:
  • Phone: 386-445-4734
  • Fax:
Mailing address:
  • Phone: 386-274-3336
  • Fax: 386-274-3660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36003666
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: