Provider Demographics
NPI:1053733253
Name:SULLIVAN, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 GLOVER CARLTON RD
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32348-7640
Mailing Address - Country:US
Mailing Address - Phone:850-584-4775
Mailing Address - Fax:850-584-4735
Practice Address - Street 1:2823 GLOVER CARLTON RD
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32348-7640
Practice Address - Country:US
Practice Address - Phone:850-584-4775
Practice Address - Fax:850-584-4735
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJB2110171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690734200Medicaid