Healthcare Provider Details

I. General information

NPI: 1699776849
Provider Name (Legal Business Name): DANIEL JAMES SULLIVAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737A LYDIG AVE
BRONX NY
10462-2103
US

IV. Provider business mailing address

737A LYDIG AVE
BRONX NY
10462-2103
US

V. Phone/Fax

Practice location:
  • Phone: 718-824-7333
  • Fax: 631-549-3267
Mailing address:
  • Phone: 718-824-7333
  • Fax: 631-549-3267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN003134
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: