Provider Demographics
NPI:1538458773
Name:SULLIVAN, CHRISTINA MARIE (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1667
Mailing Address - Country:US
Mailing Address - Phone:262-687-8460
Mailing Address - Fax:262-687-3905
Practice Address - Street 1:3821 SPRING ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53405-1667
Practice Address - Country:US
Practice Address - Phone:262-687-8460
Practice Address - Fax:262-687-3905
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.059155207VX0000X
WI63963207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400237203Medicare PIN