Provider Demographics
NPI:1518468610
Name:SULLIVAN, ISSIAH THOMAS (DC)
Entity Type:Individual
Prefix:
First Name:ISSIAH
Middle Name:THOMAS
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 1:2721 ABRAMS RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-3311
Mailing Address - Country:US
Mailing Address - Phone:817-371-9589
Mailing Address - Fax:
Practice Address - Street 1:901 N JUPITER RD STE 110
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-3243
Practice Address - Country:US
Practice Address - Phone:469-330-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13746111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor