Provider Demographics
NPI:1417538141
Name:HANBACK, SULLIVAN CLYDE (MD)
Entity Type:Individual
Prefix:DR
First Name:SULLIVAN
Middle Name:CLYDE
Last Name:HANBACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6431 FANNIN STREET
Mailing Address - Street 2:SUITE JJL 270-6
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:713-500-7878
Mailing Address - Fax:713-500-0758
Practice Address - Street 1:6431 FANNIN STREET
Practice Address - Street 2:SUITE JJL 270-6
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-500-7878
Practice Address - Fax:713-500-0758
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU4523207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine