Provider Demographics
NPI:1285192633
Name:SULLIVAN, MARTIN ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:ANTHONY
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 DRESDEN DR NE UNIT 126
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3748
Mailing Address - Country:US
Mailing Address - Phone:850-598-1119
Mailing Address - Fax:
Practice Address - Street 1:4969 ROSWELL RD STE 100-105
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-2678
Practice Address - Country:US
Practice Address - Phone:404-255-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO10176111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition