Provider Demographics
NPI:1619961281
Name:SULLIVAN, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
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 1:11 NEVINS ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3514
Mailing Address - Country:US
Mailing Address - Phone:617-789-2442
Mailing Address - Fax:617-789-4207
Practice Address - Street 1:11 NEVINS ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3514
Practice Address - Country:US
Practice Address - Phone:617-789-2442
Practice Address - Fax:617-789-4207
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA35394208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2002728Medicaid
MA2002728Medicaid
MAM08363Medicare ID - Type Unspecified