Provider Demographics
NPI:1346669660
Name:SULLIVAN, MARK FORD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:FORD
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 1:6128 BRANDON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-2693
Mailing Address - Country:US
Mailing Address - Phone:571-359-4000
Mailing Address - Fax:703-621-3793
Practice Address - Street 1:6128 BRANDON AVE STE 201
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2693
Practice Address - Country:US
Practice Address - Phone:571-359-4000
Practice Address - Fax:703-621-3793
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291511-1207R00000X
390200000X
VA0101264845207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program