Provider Demographics
NPI:1134290646
Name:SULLIVAN, MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5433
Mailing Address - Country:US
Mailing Address - Phone:319-363-3543
Mailing Address - Fax:
Practice Address - Street 1:1700 1ST AVE NE
Practice Address - Street 2:SUITE 210
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5433
Practice Address - Country:US
Practice Address - Phone:319-363-3543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00832213ES0103X
MO2003000653213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO308753201Medicaid
MO255363230Medicare PIN
MOU95702Medicare UPIN