Provider Demographics
NPI:1386650273
Name:SULLIVAN, LISA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:19818 CYPRESS BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-4399
Mailing Address - Country:US
Mailing Address - Phone:847-805-8088
Mailing Address - Fax:847-805-8844
Practice Address - Street 1:737 SAINT JOHNS AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-4650
Practice Address - Country:US
Practice Address - Phone:847-805-8088
Practice Address - Fax:847-805-8844
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36107599207KA0200X, 207RA0201X, 2080P0201X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH79608Medicare UPIN