Provider Demographics
NPI:1154647238
Name:SULLIVAN, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:SULLIVAN
Other - Last Name:DEMIREL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3101 SE 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4900
Mailing Address - Country:US
Mailing Address - Phone:479-636-9234
Mailing Address - Fax:479-636-0774
Practice Address - Street 1:3101 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4900
Practice Address - Country:US
Practice Address - Phone:479-636-9234
Practice Address - Fax:479-636-0774
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7987208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics