Provider Demographics
NPI:1932100807
Name:SULLIVAN, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-0638
Mailing Address - Country:US
Mailing Address - Phone:619-692-3977
Mailing Address - Fax:619-692-4160
Practice Address - Street 1:1835 EL CAJON BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2591
Practice Address - Country:US
Practice Address - Phone:619-692-3977
Practice Address - Fax:619-692-4160
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66543207R00000X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF21728Medicare UPIN