Provider Demographics
NPI:1578584165
Name:SULLIVAN, HEATHER E (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:E
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 COUNTY ROAD
Mailing Address - Street 2:PO BOX 385
Mailing Address - City:EASTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06242
Mailing Address - Country:US
Mailing Address - Phone:860-315-5740
Mailing Address - Fax:860-315-5741
Practice Address - Street 1:108 COUNTY RD
Practice Address - Street 2:
Practice Address - City:EASTFORD
Practice Address - State:CT
Practice Address - Zip Code:06242-7710
Practice Address - Country:US
Practice Address - Phone:860-315-5740
Practice Address - Fax:860-315-5741
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTDO1247675Medicaid
080000154Medicare ID - Type Unspecified
CTDO1247675Medicaid