Healthcare Provider Details

I. General information

NPI: 1053340372
Provider Name (Legal Business Name): JOHN JOSEPH SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11135 MONTGOMERY RD
CINCINNATI OH
45249-2308
US

IV. Provider business mailing address

4685 FOREST AVE STE C
CINCINNATI OH
45212-3359
US

V. Phone/Fax

Practice location:
  • Phone: 513-793-2220
  • Fax: 513-793-5933
Mailing address:
  • Phone: 513-793-2220
  • Fax: 513-793-5933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number35.060447
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: