Provider Demographics
NPI:1194220921
Name:AYUSO, SULLIVAN ARMANDO (MD)
Entity Type:Individual
Prefix:
First Name:SULLIVAN
Middle Name:ARMANDO
Last Name:AYUSO
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 1:5720 FOREST PARK RD APT 3207
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-6424
Mailing Address - Country:US
Mailing Address - Phone:512-970-7379
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD STE 601
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-25
Last Update Date:2018-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC238353208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery