Provider Demographics
NPI:1295293835
Name:SULLIVAN, MICHAEL BLADE II (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BLADE
Last Name:SULLIVAN
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 SW 160TH AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6314
Mailing Address - Country:US
Mailing Address - Phone:954-399-4673
Mailing Address - Fax:
Practice Address - Street 1:3601 SW 160TH AVE STE 250
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-6314
Practice Address - Country:US
Practice Address - Phone:954-399-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-02
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FLOS18349207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program