Provider Demographics
NPI:1104045137
Name:SULLIVAN, DOUGLAS E (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:E
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 MAIN AVE S
Mailing Address - Street 2:203
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2758
Mailing Address - Country:US
Mailing Address - Phone:206-683-2995
Mailing Address - Fax:206-666-6213
Practice Address - Street 1:304 MAIN AVE S
Practice Address - Street 2:203
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2758
Practice Address - Country:US
Practice Address - Phone:206-683-2995
Practice Address - Fax:206-666-6213
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034393111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU61325Medicare UPIN