Provider Demographics
NPI:1164823738
Name:SULLIVAN, KEITH EDWARD (DPT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EDWARD
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 LOS ALTOS DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3602
Mailing Address - Country:US
Mailing Address - Phone:650-200-9600
Mailing Address - Fax:
Practice Address - Street 1:1001 SNEATH LN
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2308
Practice Address - Country:US
Practice Address - Phone:650-871-8645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA372442251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic