Healthcare Provider Details

I. General information

NPI: 1932176641
Provider Name (Legal Business Name): SABRA SULLIVAN M.D., PHD.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MANNSDALE PARK DR STE 1
MADISON MS
39110-6381
US

IV. Provider business mailing address

815 HIGHWAY 80 E
CLINTON MS
39056-5252
US

V. Phone/Fax

Practice location:
  • Phone: 601-910-3004
  • Fax: 601-910-3005
Mailing address:
  • Phone: 601-910-3004
  • Fax: 601-910-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number14238
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: