Healthcare Provider Details

I. General information

NPI: 1255877643
Provider Name (Legal Business Name): JORDAN SULLIVAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N LAKE DR PODIATRIC RESIDENCY OFFICE
MILWAUKEE WI
53211-4508
US

IV. Provider business mailing address

2301 N LAKE DR PODIATRIC RESIDENCY OFFICE
MILWAUKEE WI
53211-4508
US

V. Phone/Fax

Practice location:
  • Phone: 402-310-7374
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number18096
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: