Provider Demographics
NPI:1902845035
Name:SULLIVAN, RICHARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
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 1:214 WESTBURY CT
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-2621
Mailing Address - Country:US
Mailing Address - Phone:478-953-9935
Mailing Address - Fax:727-507-3618
Practice Address - Street 1:1601 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3431
Practice Address - Country:US
Practice Address - Phone:478-542-7830
Practice Address - Fax:478-542-7940
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2023-01-13
Deactivation Date:2021-05-13
Deactivation Code:
Reactivation Date:2023-01-13
Provider Licenses
StateLicense IDTaxonomies
GA037395207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E17802Medicare UPIN