Provider Demographics
NPI:1285676106
Name:SULLIVAN, BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
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:PO BOX 1158
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70511-1158
Mailing Address - Country:US
Mailing Address - Phone:337-892-0630
Mailing Address - Fax:337-893-0403
Practice Address - Street 1:2419 ALONZO ST
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70510-4008
Practice Address - Country:US
Practice Address - Phone:337-892-0630
Practice Address - Fax:337-893-0403
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA561696907COtherBLUE CROSS
LA1422177Medicaid
P00316386OtherRAILROAD MEDICARE
LA4A388CR05Medicare PIN
LA561696907COtherBLUE CROSS
LA4A958Medicare ID - Type Unspecified