Provider Demographics
NPI:1477660165
Name:SULLUM, STANFORD NORMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:STANFORD
Middle Name:NORMAN
Last Name:SULLUM
Suffix:
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 1:1136 5TH AVE
Mailing Address - Street 2:1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128
Mailing Address - Country:US
Mailing Address - Phone:212-876-4630
Mailing Address - Fax:212-876-3478
Practice Address - Street 1:1136 5TH AVE
Practice Address - Street 2:1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128
Practice Address - Country:US
Practice Address - Phone:212-876-4630
Practice Address - Fax:212-876-3478
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120964207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
310531Medicare ID - Type Unspecified
B12728Medicare UPIN