Provider Demographics
NPI:1679516728
Name:SULLEBARGER, JOHN T (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:SULLEBARGER
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 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:813-528-4975
Mailing Address - Fax:
Practice Address - Street 1:4200 N ARMENIA AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6438
Practice Address - Country:US
Practice Address - Phone:813-284-2200
Practice Address - Fax:813-377-1700
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62629207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17787OtherBLUE CROSS BLUE SHIELD
FL370815200Medicaid
FLP01809979-RAILROADMedicare PIN
FLB78322Medicare UPIN
FL17787R-TPAMedicare PIN