Provider Demographics
NPI:1780643908
Name:SULLIVAN, BRENDAN L (MD)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 N BEAUREGARD ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1723
Mailing Address - Country:US
Mailing Address - Phone:703-436-1200
Mailing Address - Fax:703-575-9525
Practice Address - Street 1:9010 LORTON STATION BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-4792
Practice Address - Country:US
Practice Address - Phone:703-436-1200
Practice Address - Fax:703-642-0392
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2011-01-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101227543208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6721001Medicaid