Healthcare Provider Details

I. General information

NPI: 1922560713
Provider Name (Legal Business Name): NICHOLAS W SULLIVAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 DRYDEN DR
MADISON WI
53704-3015
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-241-9020
  • Fax: 608-240-4237
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number74439-21
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number74439
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: