Healthcare Provider Details

I. General information

NPI: 1912430687
Provider Name (Legal Business Name): TIMOTHY O'SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2017
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 RATZER RD STE B7
WAYNE NJ
07470-7704
US

IV. Provider business mailing address

PO BOX 416457
BOSTON MA
02241-6457
US

V. Phone/Fax

Practice location:
  • Phone: 973-317-0155
  • Fax:
Mailing address:
  • Phone: 844-362-1735
  • Fax: 973-290-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MA11147600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: