Healthcare Provider Details

I. General information

NPI: 1619961281
Provider Name (Legal Business Name): JOHN G SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 NEVINS ST SUITE 201
BRIGHTON MA
02135-3514
US

IV. Provider business mailing address

11 NEVINS ST SUITE 201
BRIGHTON MA
02135-3514
US

V. Phone/Fax

Practice location:
  • Phone: 617-789-2442
  • Fax: 617-789-4207
Mailing address:
  • Phone: 617-789-2442
  • Fax: 617-789-4207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35394
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: