Provider Demographics
NPI:1154483477
Name:SULLIVAN, WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 E HIGHWAY 90
Mailing Address - Street 2:SUITE B
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2443
Mailing Address - Country:US
Mailing Address - Phone:520-417-9729
Mailing Address - Fax:520-417-9733
Practice Address - Street 1:5100 E HIGHWAY 90
Practice Address - Street 2:SUITE B
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2443
Practice Address - Country:US
Practice Address - Phone:520-417-9729
Practice Address - Fax:520-417-9733
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMD 221762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ192774OtherAHCCCS
AZ192774OtherAHCCCS
AZ2D151Medicare ID - Type UnspecifiedMEDICARE