Provider Demographics
NPI:1043659949
Name:SULLIVAN, MARY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:SULLIVAN
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 1:8901 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889-5600
Mailing Address - Country:US
Mailing Address - Phone:575-749-3629
Mailing Address - Fax:
Practice Address - Street 1:NMRTC CAMP PENDLETON
Practice Address - Street 2:4TH FLOOR RM 4172
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:575-749-3629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101256883208D00000X
VA101256883207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice