Provider Demographics
NPI:1750496048
Name:SULLIVAN, SETH MONTGOMERY (MD)
Entity Type:Individual
Prefix:DR
First Name:SETH
Middle Name:MONTGOMERY
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SETH
Other - Middle Name:M
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:34 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-3815
Mailing Address - Country:US
Mailing Address - Phone:203-852-3045
Mailing Address - Fax:203-855-3589
Practice Address - Street 1:34 MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3815
Practice Address - Country:US
Practice Address - Phone:203-852-3045
Practice Address - Fax:203-855-3589
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT048044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100457510AMedicaid
KS100457510AMedicaid
KSH87863Medicare UPIN