Provider Demographics
NPI:1477619625
Name:SULLIVAN, DOUGLAS K (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:K
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 GEORGE F HWY
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760-5932
Mailing Address - Country:US
Mailing Address - Phone:607-754-5900
Mailing Address - Fax:607-754-3170
Practice Address - Street 1:3660 GEORGE F HWY
Practice Address - Street 2:
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-5932
Practice Address - Country:US
Practice Address - Phone:607-754-5900
Practice Address - Fax:607-754-3170
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010001111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA1323Medicare ID - Type UnspecifiedINDIVIDUAL
NYU84335Medicare UPIN
NYBA0114Medicare ID - Type UnspecifiedGROUP