Provider Demographics
NPI:1417953647
Name:SULLIVAN, PAUL EDWARD (DPM)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWARD
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:800-321-9999
Mailing Address - Fax:267-339-3761
Practice Address - Street 1:999 ROUTE 73 N STE 401
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1227
Practice Address - Country:US
Practice Address - Phone:800-321-9999
Practice Address - Fax:267-479-1321
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003899L213ES0103X
NJ25MD00267000213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8925704Medicaid
NJ8925704Medicaid