=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699776849
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL JAMES SULLIVAN DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2005
-----------------------------------------------------
Last Update Date | 10/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 737A LYDIG AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10462-2103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-824-7333
-----------------------------------------------------
Fax | 631-549-3267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 737A LYDIG AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10462-2103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-824-7333
-----------------------------------------------------
Fax | 631-549-3267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | N003134
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------