Provider Demographics
NPI:1376777078
Name:SULLIVAN, CORINNE KRAVITZ (MD)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:KRAVITZ
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CORINNE
Other - Middle Name:DORNBUSH
Other - Last Name:KRAVITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:243 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:NH
Mailing Address - Zip Code:03743
Mailing Address - Country:US
Mailing Address - Phone:603-543-6940
Mailing Address - Fax:603-543-6950
Practice Address - Street 1:7 DUNNING ST
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743
Practice Address - Country:US
Practice Address - Phone:603-542-6700
Practice Address - Fax:603-542-6730
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH16357208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH16357OtherLICENSE
NH3091289Medicaid
VT1022455Medicaid