Provider Demographics
NPI:1164481230
Name:SULLIVAN, SCOT A (MD)
Entity Type:Individual
Prefix:
First Name:SCOT
Middle Name:A
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 1:10305 SW PARK WAY STE 203
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5033
Mailing Address - Country:US
Mailing Address - Phone:503-223-8333
Mailing Address - Fax:503-595-8160
Practice Address - Street 1:10305 SW PARK WAY STE 203
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5033
Practice Address - Country:US
Practice Address - Phone:503-223-8333
Practice Address - Fax:503-595-8160
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20157207W00000X
ORMD21723207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134409OtherGROUP PIN
OK100102160BMedicaid
OR134409OtherGROUP PIN