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General NPI Number Information
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NPI Number | 1023012911
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Entity Type | Individual
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Provider Name | TIMOTHY JOHN SULLIVAN III M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/08/2005
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Last Update Date | 06/03/2015
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Provider Practice Location Address
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Address Line | 4403 HARRISON BLVD. STE 4640
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City | OGDEN
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State | UT
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Zip | 84403-3304
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Country | US
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Telephone | 801-387-4850
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Fax | 801-387-4855
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Provider Business Mailing Address
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Address Line | 4403 HARRISON BLVD. STE 4640
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City | OGDEN
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State | UT
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Zip | 84403-3304
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Country | US
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Telephone | 801-387-4850
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Fax | 801-387-4855
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207KA0200X
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Taxonomy Name | Allergy Physician
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License Number | 037913
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207KA0200X
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Taxonomy Name | Allergy Physician
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License Number | 8263858-1205
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License Number State | UT
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