Provider Demographics
NPI:1033163381
Name:SULLIVAN, CHARLES D (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 N 5TH AVE
Mailing Address - Street 2:STE 2100
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3045
Mailing Address - Country:US
Mailing Address - Phone:360-582-2850
Mailing Address - Fax:360-582-2851
Practice Address - Street 1:840 N 5TH AVE
Practice Address - Street 2:STE 2100
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3045
Practice Address - Country:US
Practice Address - Phone:360-582-2850
Practice Address - Fax:360-582-2851
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1819408Medicaid
WA0158209OtherLABOR & INDUSTRIES
WA1819408Medicaid
WA0158209OtherLABOR & INDUSTRIES
WA043600306OtherTIN