Provider Demographics
NPI:1215036603
Name:SULLIVAN, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:LAHEY CLINIC
Mailing Address - Street 2:41 MALL ROAD
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-641-0100
Mailing Address - Fax:781-744-7132
Practice Address - Street 1:37 BROADWAY
Practice Address - Street 2:LAHEY ARLINGTON
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474-5552
Practice Address - Country:US
Practice Address - Phone:781-641-0100
Practice Address - Fax:781-744-7132
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2012-12-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA40783207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2052679Medicaid
MAB02108Medicare PIN
B72581Medicare UPIN