Healthcare Provider Details

I. General information

NPI: 1598823049
Provider Name (Legal Business Name): ROBERT SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 EUBANK BOULEVARD NE SUITE 9A
ALBUQUERQUE NM
87111-3465
US

IV. Provider business mailing address

POST OFFICE BOX 685
TIJERAS NM
87059-8229
US

V. Phone/Fax

Practice location:
  • Phone: 505-286-4492
  • Fax: 505-286-4392
Mailing address:
  • Phone: 505-286-4492
  • Fax: 505-286-4392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2007-0049
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: