Provider Demographics
NPI:1548424245
Name:SULLIVAN, PEGGY S (MD)
Entity Type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:S
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PEGGY
Other - Middle Name:
Other - Last Name:SOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-6007
Practice Address - Fax:310-206-8108
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90881207ZC0500X, 207ZP0101X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A908810Medicaid
CABB498ZMedicare PIN
CABB498XMedicare PIN