Provider Demographics
NPI:1083755169
Name:O'SULLIVAN, CRAIG W (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:W
Last Name:O'SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5400 FRANTZ RD
Mailing Address - Street 2:STE 250
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:765 N HAMILTON RD
Practice Address - Street 2:STE. 255
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-8703
Practice Address - Country:US
Practice Address - Phone:614-337-9100
Practice Address - Fax:614-337-0027
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.05.9309.O207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0774694Medicaid
OH0774694Medicaid
OHO 4063751Medicare ID - Type UnspecifiedMEDICARE PIN-OHIO