Provider Demographics
NPI:1538486717
Name:SULLIVAN, TIMOTHY W (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:W
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:155 BORTHWICK AVE
Mailing Address - Street 2:SUITE 200 E
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7156
Mailing Address - Country:US
Mailing Address - Phone:603-436-1773
Mailing Address - Fax:603-427-0655
Practice Address - Street 1:155 BORTHWICK AVE
Practice Address - Street 2:SUITE 200 E
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7156
Practice Address - Country:US
Practice Address - Phone:603-436-1773
Practice Address - Fax:603-427-0655
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2020-05-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NH16565207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3098071Medicaid
NH1538486717Medicare PIN