Healthcare Provider Details

I. General information

NPI: 1285124198
Provider Name (Legal Business Name): DEIRDRE CATHERINE SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST
NEW YORK NY
10065
US

IV. Provider business mailing address

15 PENNSYLVANIA AVE
LONG BEACH NY
11561-1619
US

V. Phone/Fax

Practice location:
  • Phone: 516-732-1088
  • Fax:
Mailing address:
  • Phone: 516-732-1088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: