Provider Demographics
NPI:1578692760
Name:SULLIVAN, DAVID MATTHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MATTHEW
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BIDDLE AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:HARRISON
Mailing Address - State:OH
Mailing Address - Zip Code:45030-2528
Mailing Address - Country:US
Mailing Address - Phone:513-367-2090
Mailing Address - Fax:513-367-7083
Practice Address - Street 1:104 BIDDLE AVE
Practice Address - Street 2:SUITE G
Practice Address - City:HARRISON
Practice Address - State:OH
Practice Address - Zip Code:45030-2528
Practice Address - Country:US
Practice Address - Phone:513-367-2090
Practice Address - Fax:513-367-7083
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1069111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT48076Medicare UPIN
OHSU0553451Medicare ID - Type Unspecified