Provider Demographics
NPI:1043436009
Name:SULT, JENNIFER MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:SULT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-8931
Mailing Address - Country:US
Mailing Address - Phone:574-223-2020
Mailing Address - Fax:574-223-5847
Practice Address - Street 1:1400 E 9TH ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-8931
Practice Address - Country:US
Practice Address - Phone:574-223-2020
Practice Address - Fax:574-223-5847
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062520A208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200863600Medicaid
IN200863600Medicaid
M400071772Medicare PIN