Provider Demographics
NPI:1508895988
Name:SULLIVAN, THOMAS C (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:SULLIVAN
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 1:311 MORROW ST N
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-2516
Mailing Address - Country:US
Mailing Address - Phone:479-394-6100
Mailing Address - Fax:479-394-4577
Practice Address - Street 1:400 CRESTWOOD CIR
Practice Address - Street 2:SUITE L
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-5511
Practice Address - Country:US
Practice Address - Phone:479-394-1414
Practice Address - Fax:479-394-2612
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41748208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C32032Medicare UPIN