Provider Demographics
NPI:1083638795
Name:SULLIVAN, CORDY E (MD)
Entity Type:Individual
Prefix:DR
First Name:CORDY
Middle Name:E
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 1:67 KENDALL ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CLIFTON SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:14432-9701
Mailing Address - Country:US
Mailing Address - Phone:315-462-9482
Mailing Address - Fax:315-462-5438
Practice Address - Street 1:350 PARRISH ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1731
Practice Address - Country:US
Practice Address - Phone:585-396-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134827207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00964223Medicaid
NYDD1435Medicare PIN
D01767Medicare UPIN