Healthcare Provider Details

I. General information

NPI: 1023012911
Provider Name (Legal Business Name): TIMOTHY JOHN SULLIVAN III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 HARRISON BLVD. STE 4640
OGDEN UT
84403-3304
US

IV. Provider business mailing address

4403 HARRISON BLVD. STE 4640
OGDEN UT
84403-3304
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-4850
  • Fax: 801-387-4855
Mailing address:
  • Phone: 801-387-4850
  • Fax: 801-387-4855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number037913
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number8263858-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: