Healthcare Provider Details

I. General information

NPI: 1326522046
Provider Name (Legal Business Name): LUTHER BOYD SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 BRYAN PL
HAGERSTOWN MD
21740-4534
US

IV. Provider business mailing address

1010 VERMONT AVE NW
WASHINGTON DC
20005-4902
US

V. Phone/Fax

Practice location:
  • Phone: 202-277-8261
  • Fax:
Mailing address:
  • Phone: 844-381-4432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: