Healthcare Provider Details

I. General information

NPI: 1568880094
Provider Name (Legal Business Name): ZACHARY JOEL SULLIVAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 WEST FWY STE 700
FORT WORTH TX
76116-2180
US

IV. Provider business mailing address

6500 WEST FWY STE 700
FORT WORTH TX
76116-2180
US

V. Phone/Fax

Practice location:
  • Phone: 817-527-8621
  • Fax: 801-901-1194
Mailing address:
  • Phone: 817-527-8621
  • Fax: 817-502-3632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberQ6577
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: