Provider Demographics
NPI:1255370326
Name:SULLIVAN, EUGENE DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:DAVID
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 1:1000 ASYLUM AVE
Mailing Address - Street 2:SUITE 2120
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105
Mailing Address - Country:US
Mailing Address - Phone:860-246-4000
Mailing Address - Fax:860-527-6985
Practice Address - Street 1:1000 ASYLUM AVE
Practice Address - Street 2:SUITE 2120
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105
Practice Address - Country:US
Practice Address - Phone:860-246-4000
Practice Address - Fax:860-527-6985
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT021621174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001216217Medicaid
CT330000118Medicare ID - Type UnspecifiedMEDICARE ID
B37460Medicare UPIN
CT001216217Medicaid