Provider Demographics
NPI:1669638219
Name:SULLIVAN, JASON PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:PATRICK
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6001 WESTOWN PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-7702
Mailing Address - Country:US
Mailing Address - Phone:515-224-1414
Mailing Address - Fax:515-224-5140
Practice Address - Street 1:6001 WESTOWN PKWY
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-7719
Practice Address - Country:US
Practice Address - Phone:515-224-1414
Practice Address - Fax:515-224-5140
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-40971207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1669638219Medicaid