Provider Demographics
NPI:1073524088
Name:ROBERT W SULLIVAN DPM PC
Entity Type:Organization
Organization Name:ROBERT W SULLIVAN DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-363-3338
Mailing Address - Street 1:1700 PLEASURE HOUSE RD
Mailing Address - Street 2:SUITE 101-102
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-4053
Mailing Address - Country:US
Mailing Address - Phone:757-363-3338
Mailing Address - Fax:757-363-3453
Practice Address - Street 1:1700 PLEASURE HOUSE RD
Practice Address - Street 2:SUITE 101-102
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-4053
Practice Address - Country:US
Practice Address - Phone:757-363-3338
Practice Address - Fax:757-363-3453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000735213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA571322OtherOPTIMA
VA480026957OtherRR MEDICARE
VA571322OtherOPTIMA
VAC08789Medicare PIN