Provider Demographics
NPI:1821208182
Name:MARK S. SULLIVAN, M.D., PLLC
Entity Type:Organization
Organization Name:MARK S. SULLIVAN, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STOVER
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-947-0676
Mailing Address - Street 1:3366 NW EXPRESSWAY
Mailing Address - Street 2:SUITE 720
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4462
Mailing Address - Country:US
Mailing Address - Phone:405-947-0676
Mailing Address - Fax:405-945-4876
Practice Address - Street 1:3366 NW EXPRESSWAY ST
Practice Address - Street 2:SUITE 720
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4462
Practice Address - Country:US
Practice Address - Phone:405-947-0676
Practice Address - Fax:405-945-4876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOKC8667174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========Medicare PIN
OKD42865Medicare UPIN