Provider Demographics
NPI:1083633408
Name:SULLIVAN, EUGENE MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:MICHAEL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4886
Mailing Address - Country:US
Mailing Address - Phone:516-248-3737
Mailing Address - Fax:516-248-7304
Practice Address - Street 1:1103 STEWART AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4886
Practice Address - Country:US
Practice Address - Phone:516-248-3737
Practice Address - Fax:516-248-7304
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227428207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW08521Medicare ID - Type Unspecified