Provider Demographics
NPI:1497701130
Name:SULLIVAN, CARY PATRICK (DO)
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:PATRICK
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DO
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 446
Mailing Address - Street 2:
Mailing Address - City:VIAN
Mailing Address - State:OK
Mailing Address - Zip Code:74962-0446
Mailing Address - Country:US
Mailing Address - Phone:918-773-5228
Mailing Address - Fax:918-773-8482
Practice Address - Street 1:300 N THORNTON ST.
Practice Address - Street 2:
Practice Address - City:VIAN
Practice Address - State:OK
Practice Address - Zip Code:74962-0446
Practice Address - Country:US
Practice Address - Phone:918-773-5228
Practice Address - Fax:918-773-8482
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2148207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731153208003OtherBLUE CROSS BLUE SHIELD
OK100254810GMedicaid
OK100254810EMedicaid
OKE03553Medicare UPIN
OK100254810EMedicaid