Provider Demographics
NPI:1376108050
Name:SULLIVAN, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MICHIGAN AVENUE NW
Mailing Address - Street 2:WEST WING, 3RD FLOOR, SUITE 200
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010
Mailing Address - Country:US
Mailing Address - Phone:202-476-4568
Mailing Address - Fax:
Practice Address - Street 1:111 MICHIGAN AVENUE NW
Practice Address - Street 2:WEST WING, 3RD FLOOR, SUITE 200
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010
Practice Address - Country:US
Practice Address - Phone:202-476-4568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
DCMD210002092208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program