Provider Demographics
NPI:1831301639
Name:SULLIVAN, DAN T (MD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:T
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 1:3780 E POND APPLE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-4147
Mailing Address - Country:US
Mailing Address - Phone:417-883-7995
Mailing Address - Fax:
Practice Address - Street 1:3780 E POND APPLE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-4147
Practice Address - Country:US
Practice Address - Phone:417-883-7995
Practice Address - Fax:417-882-2560
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR4804247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
A 13482Medicare UPIN