Provider Demographics
NPI:1437190436
Name:SULLIVAN, ROBERT A JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:SULLIVAN
Suffix:JR
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:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:3619 OLD FOREST RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501
Practice Address - Country:US
Practice Address - Phone:434-385-8190
Practice Address - Fax:434-385-5873
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055474207K00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1982869897Medicaid
VAVVT217AOtherMEDICARE PTAN