Provider Demographics
NPI:1417956400
Name:SULLIVAN, TIMOTHY JAMES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:SULLIVAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1021 W OAKLAND AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2191
Mailing Address - Country:US
Mailing Address - Phone:423-915-3104
Mailing Address - Fax:423-952-3109
Practice Address - Street 1:2300 PAVILION DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4622
Practice Address - Country:US
Practice Address - Phone:423-587-5571
Practice Address - Fax:423-587-5237
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD185022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3882277Medicaid
TN3882277Medicaid