Provider Demographics
NPI:1669445300
Name:SULLIVAN, ROBERT W (DPM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 PLEASURE HOUSE RD
Mailing Address - Street 2:SUITE 101-102
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-4053
Mailing Address - Country:US
Mailing Address - Phone:757-363-3338
Mailing Address - Fax:757-363-3453
Practice Address - Street 1:1700 PLEASURE HOUSE RD
Practice Address - Street 2:SUITE 101-102
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-4053
Practice Address - Country:US
Practice Address - Phone:757-363-3338
Practice Address - Fax:757-363-3453
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000735213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA15443OtherOPTIMA
VA412179OtherMDIPA
VA009303669Medicaid
VA305079OtherANTHEM
VA480026957OtherRR MEDICARE
VA4056110001Medicare NSC
VA009303669Medicaid
VA305079OtherANTHEM