Healthcare Provider Details

I. General information

NPI: 1477660165
Provider Name (Legal Business Name): STANFORD NORMAN SULLUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 5TH AVE 1B
NEW YORK NY
10128
US

IV. Provider business mailing address

1136 5TH AVE 1B
NEW YORK NY
10128
US

V. Phone/Fax

Practice location:
  • Phone: 212-876-4630
  • Fax: 212-876-3478
Mailing address:
  • Phone: 212-876-4630
  • Fax: 212-876-3478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number120964
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: