Provider Demographics
NPI:1275506578
Name:SULLIVAN, JOHN WARREN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WARREN
Last Name:SULLIVAN
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 1:175 DWIGHT RD
Mailing Address - Street 2:STE 301
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106
Mailing Address - Country:US
Mailing Address - Phone:413-737-4746
Mailing Address - Fax:413-565-2297
Practice Address - Street 1:175 DWIGHT RD
Practice Address - Street 2:STE 301
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106
Practice Address - Country:US
Practice Address - Phone:413-737-4746
Practice Address - Fax:413-565-2297
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA358402084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Not Answered2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
Y02043Medicare ID - Type Unspecified
B99494Medicare UPIN