Provider Demographics
NPI:1376923292
Name:SULLIVAN, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
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 1:8901 ROCKVILLE PIKE
Mailing Address - Street 2:WALTER REED
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BLDG A120, MCAS NEW RIVER, JACKSONVILLE, NC, 28445
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:NC
Practice Address - Zip Code:28445-0001
Practice Address - Country:US
Practice Address - Phone:910-467-3415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA01012622002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program