Healthcare Provider Details

I. General information

NPI: 1023162559
Provider Name (Legal Business Name): ANDRE JAWANN SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 MDG, 340 MAGNOLIA CIRCLE
TYNDALL AFB FL
32403
US

IV. Provider business mailing address

325 MDG, 340 MAGNOLIA CIRCLE
TYNDALL AFB FL
32403
US

V. Phone/Fax

Practice location:
  • Phone: 703-731-2566
  • Fax:
Mailing address:
  • Phone: 703-731-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM-16066
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR9446
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number41880
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.175093
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: