Provider Demographics
NPI:1710098173
Name:SULLIVAN, BRENT C (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:C
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 1:38135 MARKET SQUARE
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542
Mailing Address - Country:US
Mailing Address - Phone:813-528-4975
Mailing Address - Fax:
Practice Address - Street 1:14547 BRUCE B DOWNS BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613
Practice Address - Country:US
Practice Address - Phone:813-979-7733
Practice Address - Fax:813-355-5098
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69655208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269015200Medicaid
FLP00085921OtherRR MEDICARE
G19984Medicare UPIN
FL28241XMedicare PIN