Provider Demographics
NPI:1629132683
Name:SULTAN, TIPU (MD)
Entity Type:Individual
Prefix:DR
First Name:TIPU
Middle Name:
Last Name:SULTAN
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 1:11585 W FLORISSANT AVE
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-6740
Mailing Address - Country:US
Mailing Address - Phone:314-921-5600
Mailing Address - Fax:314-921-8273
Practice Address - Street 1:11585 W FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6740
Practice Address - Country:US
Practice Address - Phone:314-921-5600
Practice Address - Fax:314-921-8273
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7234207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA09796Medicare UPIN