Provider Demographics
NPI:1568417053
Name:O'SULLIVAN, ADELE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ADELE
Middle Name:MARIE
Last Name:O'SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11999 CHALON RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-1524
Mailing Address - Country:US
Mailing Address - Phone:310-889-2153
Mailing Address - Fax:310-472-5982
Practice Address - Street 1:11999 CHALON RD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-1524
Practice Address - Country:US
Practice Address - Phone:310-889-2153
Practice Address - Fax:310-472-5982
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15677207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ275299Medicaid
E00280Medicare UPIN