Provider Demographics
NPI:1932470291
Name:SULLIVAN, ANDREW (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 1ST ST BLDG 1402
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93043-4316
Mailing Address - Country:US
Mailing Address - Phone:936-523-0454
Mailing Address - Fax:805-982-2071
Practice Address - Street 1:162 1ST ST BLDG 1402
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93043-4316
Practice Address - Country:US
Practice Address - Phone:936-523-0454
Practice Address - Fax:805-982-2071
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203574208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice