Provider Demographics
NPI:1003862673
Name:C. PATRICK SULLIVAN,DO
Entity Type:Organization
Organization Name:C. PATRICK SULLIVAN,DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARY
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-773-5228
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:VIAN
Mailing Address - State:OK
Mailing Address - Zip Code:74962-0446
Mailing Address - Country:US
Mailing Address - Phone:918-773-5228
Mailing Address - Fax:918-773-8482
Practice Address - Street 1:200 NORTH THORNTON
Practice Address - Street 2:
Practice Address - City:VIAN
Practice Address - State:OK
Practice Address - Zip Code:74962-0446
Practice Address - Country:US
Practice Address - Phone:918-773-5228
Practice Address - Fax:918-773-8482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100254810EMedicaid
OK100254810GMedicaid
OK100757080GMedicaid
OK100254810GMedicaid