Provider Demographics
NPI:1003019621
Name:SULLIVAN, DONALD RICHARD (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:RICHARD
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 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:UHN67
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-6949
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:UHN67
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-6949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-10
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD151732207RP1001X, 207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine