Provider Demographics
NPI:1750481099
Name:SULLIVAN, TIM (MD)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
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 1:12791 CABEZUT RD
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5926
Mailing Address - Country:US
Mailing Address - Phone:209-532-5524
Mailing Address - Fax:209-532-1513
Practice Address - Street 1:12791 CABEZUT RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5926
Practice Address - Country:US
Practice Address - Phone:209-532-5524
Practice Address - Fax:209-532-1513
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2019-07-29
Deactivation Date:2019-07-12
Deactivation Code:
Reactivation Date:2019-07-29
Provider Licenses
StateLicense IDTaxonomies
IA34411208000000X
CAC55917208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics