Provider Demographics
NPI:1184604761
Name:SULLIVAN, JOHN THOMAS (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
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 1:303 SOUTHWEST 16TH STREET
Mailing Address - Street 2:SUITE #7
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712
Mailing Address - Country:US
Mailing Address - Phone:479-271-8100
Mailing Address - Fax:479-271-8548
Practice Address - Street 1:303 SOUTHWEST 16TH STREET
Practice Address - Street 2:SUITE #7
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712
Practice Address - Country:US
Practice Address - Phone:479-271-8100
Practice Address - Fax:479-271-8548
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1574111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W407Medicare PIN