Provider Demographics
NPI:1689730863
Name:SULLIVAN, MARK ALLAN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLAN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4196 AVERY RD
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-1004
Mailing Address - Country:US
Mailing Address - Phone:614-876-1111
Mailing Address - Fax:614-876-5600
Practice Address - Street 1:4196 AVERY RD
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-1004
Practice Address - Country:US
Practice Address - Phone:614-876-1111
Practice Address - Fax:614-876-5600
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2612111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI2195735Medicaid
OHU55775Medicare UPIN
OHNE 4019481Medicare ID - Type Unspecified