Provider Demographics
NPI:1992023493
Name:SULLIVAN, SHEILA KERRI (DO)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:KERRI
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3320
Mailing Address - Country:US
Mailing Address - Phone:920-261-8225
Mailing Address - Fax:920-261-5343
Practice Address - Street 1:123 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 1002
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3320
Practice Address - Country:US
Practice Address - Phone:920-261-8225
Practice Address - Fax:920-261-5343
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61084-21207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1992023493Medicaid
WI1992023493Medicaid