Provider Demographics
NPI:1275506925
Name:SULLIVAN, TERRENCE (DO)
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2026
Mailing Address - Country:US
Mailing Address - Phone:817-738-0333
Mailing Address - Fax:
Practice Address - Street 1:2000 S FM 51
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3702
Practice Address - Country:US
Practice Address - Phone:940-627-5921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8760M6Medicare ID - Type Unspecified
TXE84925Medicare UPIN