Provider Demographics
NPI:1740200377
Name:SULLIVAN, PAUL S (DO)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 N MAIN ST
Mailing Address - Street 2:SUITE 245
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2515
Mailing Address - Country:US
Mailing Address - Phone:860-236-3000
Mailing Address - Fax:860-236-3002
Practice Address - Street 1:345 N MAIN ST
Practice Address - Street 2:SUITE 245
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2515
Practice Address - Country:US
Practice Address - Phone:860-236-3000
Practice Address - Fax:860-236-3002
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001005273Medicaid
CT001005273Medicaid