Provider Demographics
NPI:1477580306
Name:SULLIVAN, EDWIN J (DO FACOS)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DO FACOS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 B MARKET ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SADDLE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07663-8941
Mailing Address - Country:US
Mailing Address - Phone:201-843-7942
Mailing Address - Fax:201-712-7902
Practice Address - Street 1:449 B MARKET ST
Practice Address - Street 2:SUITE B
Practice Address - City:SADDLE BROOK
Practice Address - State:NJ
Practice Address - Zip Code:07663-8941
Practice Address - Country:US
Practice Address - Phone:201-843-7942
Practice Address - Fax:201-712-7902
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB25068208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1464906Medicaid
G06219Medicare UPIN
NJSU452040Medicare ID - Type Unspecified