Provider Demographics
NPI:1043303548
Name:SULLIVAN, JOSEPH C III (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:C
Last Name:SULLIVAN
Suffix:III
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:PO BOX 116700
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6700
Mailing Address - Country:US
Mailing Address - Phone:904-236-5884
Mailing Address - Fax:904-346-4334
Practice Address - Street 1:11375 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5409
Practice Address - Country:US
Practice Address - Phone:904-236-5884
Practice Address - Fax:904-346-4334
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0528372085N0700X
TN549942085R0202X
AL248712085R0202X
FLME1606692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04923068Medicaid
AL051543136OtherBCBS
AL051543144OtherBCBS
AL009942662Medicaid
AL009942659Medicaid
GA199147922AMedicaid
AL009942658Medicaid
AL009942660Medicaid
AL051543137OtherBCBS
AL051543142OtherBCBS
ALP00406959OtherRR MEDICARE
GA30BDLPGMedicare ID - Type Unspecified
AL051543136OtherBCBS
SCG52837Medicare ID - Type Unspecified
AL009942659Medicaid