Provider Demographics
NPI:1225128952
Name:SULLIVAN, JARED M (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10 PIHLMAN PL
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-2707
Mailing Address - Country:US
Mailing Address - Phone:973-768-7967
Mailing Address - Fax:973-778-6014
Practice Address - Street 1:1117 US HIGHWAY 46 STE 202
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2450
Practice Address - Country:US
Practice Address - Phone:973-779-1221
Practice Address - Fax:973-778-6014
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA076546207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0079553Medicaid
082155Medicare ID - Type Unspecified
NJ0079553Medicaid