Provider Demographics
NPI:1518967843
Name:SULLIVAN, JOHN K (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:49 SPRING ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8926
Practice Address - Country:US
Practice Address - Phone:207-883-1414
Practice Address - Fax:207-883-1518
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-10-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MEMD106812084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30004047Medicaid
ME290400099Medicaid
ME01504301Medicare PIN
C58952Medicare UPIN
ME015043Medicare PIN
ME290400099Medicaid
NH30004047Medicaid
MEP01079467Medicare PIN