Provider Demographics
NPI:1265469209
Name:SULLIVAN, BRIAN SCOTT (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:SCOTT
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MORRIS AVE
Mailing Address - Street 2:STE 304
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1427
Mailing Address - Country:US
Mailing Address - Phone:973-258-0111
Mailing Address - Fax:973-258-0122
Practice Address - Street 1:100 MORRIS AVE
Practice Address - Street 2:STE 304
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1427
Practice Address - Country:US
Practice Address - Phone:973-258-0111
Practice Address - Fax:973-258-0123
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00275100213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU95503Medicare UPIN
NJ070207DPJMedicare ID - Type Unspecified