1669445300 NPI number — ROBERT W SULLIVAN DPM

Table of content: ROBERT W SULLIVAN DPM (NPI 1669445300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669445300 NPI number — ROBERT W SULLIVAN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
ROBERT
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669445300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 PLEASURE HOUSE RD
Provider Second Line Business Mailing Address:
SUITE 101-102
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23455-4053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-363-3338
Provider Business Mailing Address Fax Number:
757-363-3453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 PLEASURE HOUSE RD
Provider Second Line Business Practice Location Address:
SUITE 101-102
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23455-4053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-363-3338
Provider Business Practice Location Address Fax Number:
757-363-3453
Provider Enumeration Date:
02/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  0103000735 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 15443 . This is a "OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 412179 . This is a "MDIPA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 009303669 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 305079 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 480026957 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com