Provider Demographics
NPI:1043296874
Name:SULLIVAN, WILLIAM T (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:T
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 1:8401 DATAPOINT, SUITE 600
Mailing Address - Street 2:P. O. BOX 29441
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-0441
Mailing Address - Country:US
Mailing Address - Phone:210-616-7700
Mailing Address - Fax:210-616-7709
Practice Address - Street 1:8401 DATAPOINT DR STE 600
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5907
Practice Address - Country:US
Practice Address - Phone:210-616-7700
Practice Address - Fax:210-616-7709
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF45782085B0100X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L26946OtherMEDICARE - STRIC
TXP00829954OtherRAILROAD MEDICARE
TX1345241-08Medicaid
TX1345241-09Medicaid
TXP00845686OtherRAILROAD MEDICARE
TX1345241-10Medicaid
TXF4578OtherTEXAS MEDICAL LICENSE
TX1345241-09Medicaid