Provider Demographics
NPI:1801857693
Name:SULLIVAN, CHARLES DAVID
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LILE CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6242
Mailing Address - Country:US
Mailing Address - Phone:501-225-7711
Mailing Address - Fax:501-225-7108
Practice Address - Street 1:1 LILE CT
Practice Address - Street 2:SUITE 101
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6242
Practice Address - Country:US
Practice Address - Phone:501-225-7711
Practice Address - Fax:501-225-7108
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4650207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARD84343Medicare UPIN
AR55178Medicare ID - Type Unspecified