Healthcare Provider Details

I. General information

NPI: 1427296375
Provider Name (Legal Business Name): JOSEPH M. SULLIVAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 01/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2144 CAPEWOOD DR
HUDDLESTON VA
24104-3430
US

IV. Provider business mailing address

2144 CAPEWOOD DR
HUDDLESTON VA
24104-3430
US

V. Phone/Fax

Practice location:
  • Phone: 540-904-8661
  • Fax:
Mailing address:
  • Phone: 540-904-8661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103300735
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: