Provider Demographics
NPI:1598823049
Name:SULLIVAN, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
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:POST OFFICE BOX 685
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-8229
Mailing Address - Country:US
Mailing Address - Phone:505-286-4492
Mailing Address - Fax:505-286-4392
Practice Address - Street 1:3900 EUBANK BOULEVARD NE
Practice Address - Street 2:SUITE 9A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3465
Practice Address - Country:US
Practice Address - Phone:505-286-4492
Practice Address - Fax:505-286-4392
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-00492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87670780Medicaid
NM87670780Medicaid
NMNMA100350Medicare PIN
CAE02846Medicare UPIN