Provider Demographics
NPI:1447244785
Name:SULLIVAN, TERRENCE R (MD)
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:R
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TERRY
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:16450 MATILIJA DR
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-3080
Mailing Address - Country:US
Mailing Address - Phone:408-590-3159
Mailing Address - Fax:
Practice Address - Street 1:16450 MATILIJA DR
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-3080
Practice Address - Country:US
Practice Address - Phone:408-590-3159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25099208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00061715OtherRAILROAD MEDICARE
CA00G250990Medicare ID - Type Unspecified
A42524Medicare UPIN