Provider Demographics
NPI:1255384608
Name:SULLIVAN, PETER VINCENT (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:VINCENT
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 1:6200 HICKORY HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-1484
Mailing Address - Country:US
Mailing Address - Phone:936-756-0948
Mailing Address - Fax:
Practice Address - Street 1:100 W CROSS ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TX
Practice Address - Zip Code:77864-2432
Practice Address - Country:US
Practice Address - Phone:936-348-2631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1689207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00218410Medicare PIN
TXB03224Medicare UPIN
TX8D5674Medicare PIN