Provider Demographics
NPI:1295742419
Name:SULLIVAN, THOMAS S (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
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 1:5440 CHANDLEY FARM CIR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-1239
Mailing Address - Country:US
Mailing Address - Phone:703-815-1124
Mailing Address - Fax:703-815-7411
Practice Address - Street 1:12018 SUNRISE VALLEY DR
Practice Address - Street 2:SUITE 400
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3432
Practice Address - Country:US
Practice Address - Phone:571-262-5200
Practice Address - Fax:571-521-7249
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043001207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010051185Medicaid
VA010051185Medicaid