Provider Demographics
NPI:1689771636
Name:SULLIVAN, ERIC M (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:M
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:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-342-2134
Mailing Address - Fax:541-684-3074
Practice Address - Street 1:920 COUNTRY CLUB RD
Practice Address - Street 2:SUITE 200A
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6024
Practice Address - Country:US
Practice Address - Phone:541-342-2134
Practice Address - Fax:541-684-3074
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD161287207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500666109Medicaid
R172600Medicare PIN
00A867550Medicare ID - Type Unspecified