Provider Demographics
NPI:1073595377
Name:SULLIVAN, MARK STOVER (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STOVER
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3366 NW EXPRESSWAY
Mailing Address - Street 2:SUITE 720
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4462
Mailing Address - Country:US
Mailing Address - Phone:405-947-0676
Mailing Address - Fax:405-945-4876
Practice Address - Street 1:3366 NW EXPRESSWAY
Practice Address - Street 2:SUITE 720
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4462
Practice Address - Country:US
Practice Address - Phone:405-947-0676
Practice Address - Fax:405-945-4876
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK8667207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD42865Medicare UPIN