Provider Demographics
NPI:1164592044
Name:SULLIVAN, BRYAN TIPTON (DPM)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:TIPTON
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 DUNBARTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-982-3338
Mailing Address - Fax:601-982-2253
Practice Address - Street 1:1915 DUNBARTON DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-982-3338
Practice Address - Fax:601-982-2253
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80089213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00012910Medicaid
480007636OtherRAILROAD MEDICARE
480007636OtherRAILROAD MEDICARE
480000022Medicare ID - Type Unspecified
MS00012910Medicaid