Provider Demographics
NPI:1609361344
Name:SULLIVAN, MAIA ELISE (DO)
Entity Type:Individual
Prefix:DR
First Name:MAIA
Middle Name:ELISE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MAIA
Other - Middle Name:ELISE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9686
Mailing Address - Country:US
Mailing Address - Phone:616-252-7604
Mailing Address - Fax:616-252-0391
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9686
Practice Address - Country:US
Practice Address - Phone:616-252-7604
Practice Address - Fax:616-252-0391
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010224168207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology