Provider Demographics
NPI:1093805897
Name:SULLIVAN, WILLIAM J (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
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:PO BOX 1023
Mailing Address - Street 2:
Mailing Address - City:FRONTENAC
Mailing Address - State:KS
Mailing Address - Zip Code:66763-1023
Mailing Address - Country:US
Mailing Address - Phone:620-231-8849
Mailing Address - Fax:620-231-8847
Practice Address - Street 1:608 WILLARD
Practice Address - Street 2:
Practice Address - City:FRONTENAC
Practice Address - State:KS
Practice Address - Zip Code:66763-2120
Practice Address - Country:US
Practice Address - Phone:620-231-8849
Practice Address - Fax:620-231-8847
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-25406207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200213791OtherTRICARE
KSP00077657OtherRR MEDICARE
KS100234810DMedicaid
KS103449OtherMEDICARE
KS103449OtherBCBS
KS110994OtherMEDICARE
KS110994OtherGROUP BCBS
KS189381OtherCOVENTRY
KSDA9115OtherGRP RR MEDICARE
KS189381OtherCOVENTRY