Provider Demographics
NPI:1225070022
Name:SULLIVAN, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2200
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NH
Mailing Address - Zip Code:03031-4200
Mailing Address - Country:US
Mailing Address - Phone:603-673-9411
Mailing Address - Fax:603-673-9899
Practice Address - Street 1:172 MIDDLESEX AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887-2737
Practice Address - Country:US
Practice Address - Phone:978-658-4432
Practice Address - Fax:978-658-5751
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA33493207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA706387OtherTUFTS HEALTH PLAN
164920OtherCIGNA HEALTHSOURCE
MA2061899Medicaid
70503OtherHARVARD PILGRIM
MAB52010OtherBLUE CROSS BLUE SHIELD
MA0015705OtherNEIGHBORHOOD HEALTH
MA35943OtherFALLON COMMUNITY HEALTH
B10030001OtherCIGNA
B73303Medicare UPIN
164920OtherCIGNA HEALTHSOURCE
110082795Medicare ID - Type UnspecifiedRAILROAD MEDICARE