Provider Demographics
NPI:1154856987
Name:SULLIVAN, DAVID (LMT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 SARATOGA ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1892
Mailing Address - Country:US
Mailing Address - Phone:718-825-7245
Mailing Address - Fax:
Practice Address - Street 1:100 N GRAPE ST APT 303
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3151
Practice Address - Country:US
Practice Address - Phone:718-825-7245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-30
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22561225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist