Provider Demographics
NPI:1932116746
Name:SULLIVAN, MICHAEL W (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-5455
Mailing Address - Country:US
Mailing Address - Phone:405-447-5181
Mailing Address - Fax:405-447-5182
Practice Address - Street 1:601 ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5455
Practice Address - Country:US
Practice Address - Phone:405-447-5181
Practice Address - Fax:405-447-5182
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3224111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100830210AMedicaid
OK100830210AMedicaid