Provider Demographics
NPI:1144244476
Name:SULLIVAN, KATHLEEN BEATRICE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:BEATRICE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10429
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-0429
Mailing Address - Country:US
Mailing Address - Phone:949-417-1812
Mailing Address - Fax:949-417-1803
Practice Address - Street 1:24451 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3689
Practice Address - Country:US
Practice Address - Phone:949-837-4500
Practice Address - Fax:949-837-4621
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49346207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G493460OtherBLUE SHIELD ID #
CA00G493460385OtherCALOPTIMA ID #
CA00G493460Medicaid
CAA92893Medicare UPIN
CA00G493460385OtherCALOPTIMA ID #