Healthcare Provider Details

I. General information

NPI: 1659363083
Provider Name (Legal Business Name): JOHN SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37026 US HIGHWAY 19 N
PALM HARBOR FL
34684-1109
US

IV. Provider business mailing address

37026 US HIGHWAY 19 N
PALM HARBOR FL
34684-1109
US

V. Phone/Fax

Practice location:
  • Phone: 727-938-1935
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME0043162
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: