Provider Demographics
NPI:1669478798
Name:SULLIVAN, KENT (MD)
Entity Type:Individual
Prefix:
First Name:KENT
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 1:1530 N 115TH ST
Mailing Address - Street 2:STE 107
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-8411
Mailing Address - Country:US
Mailing Address - Phone:206-368-6160
Mailing Address - Fax:206-368-6562
Practice Address - Street 1:1530 N 115TH ST
Practice Address - Street 2:STE 107
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8411
Practice Address - Country:US
Practice Address - Phone:206-368-6560
Practice Address - Fax:206-368-6562
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0001591207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1100791Medicaid
WAP00170689OtherRAILROAD MEDICARE
WA1100791Medicaid
A05736Medicare UPIN