Provider Demographics
NPI:1295022903
Name:SULLIVAN, JOSEPH R (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
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 1:2000 E LAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-6053
Mailing Address - Country:US
Mailing Address - Phone:414-744-6589
Mailing Address - Fax:
Practice Address - Street 1:2000 E LAYTON AVE
Practice Address - Street 2:
Practice Address - City:ST FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235-6053
Practice Address - Country:US
Practice Address - Phone:414-744-6589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65368-21208600000X
MI5101019532208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100058377Medicaid
WIK400311109/02120Medicare PIN