Provider Demographics
NPI:1679239438
Name:SULLIVAN, BRIAN PAUL
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:PAUL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRIAN
Other - Middle Name:PAUL
Other - Last Name:AIKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6120 N MERIDIAN AVE APT 506
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-1279
Mailing Address - Country:US
Mailing Address - Phone:918-316-0112
Mailing Address - Fax:
Practice Address - Street 1:6120 N MERIDIAN AVE APT 506
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-1279
Practice Address - Country:US
Practice Address - Phone:918-316-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist