Provider Demographics
NPI:1285675405
Name:SULLIVAN, JESSE GEORGE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:GEORGE
Last Name:SULLIVAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1116 MONTREAL DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-5349
Mailing Address - Country:US
Mailing Address - Phone:405-354-9769
Mailing Address - Fax:
Practice Address - Street 1:2001 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-2107
Practice Address - Country:US
Practice Address - Phone:405-262-2114
Practice Address - Fax:405-262-2306
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK12233208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD35326Medicare UPIN