Provider Demographics
NPI:1114049228
Name:SULLIVAN, JOHN M (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
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 1:2839 TOPEKA ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-1754
Mailing Address - Country:US
Mailing Address - Phone:361-854-3200
Mailing Address - Fax:
Practice Address - Street 1:3945 US HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-4531
Practice Address - Country:US
Practice Address - Phone:361-767-8332
Practice Address - Fax:361-767-1465
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5605111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00519EMedicare ID - Type Unspecified