Provider Demographics
NPI:1922387091
Name:SULLIVAN, TOLLIN KNIGHT (MD)
Entity Type:Individual
Prefix:
First Name:TOLLIN
Middle Name:KNIGHT
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 1:2510 AIRPARK DR STE 203
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2461
Mailing Address - Country:US
Mailing Address - Phone:530-244-4034
Mailing Address - Fax:530-244-0375
Practice Address - Street 1:2510 AIRPARK DR STE 201
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001
Practice Address - Country:US
Practice Address - Phone:732-294-2540
Practice Address - Fax:530-244-1821
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA130084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA129675Medicare PIN