Provider Demographics
NPI:1356353965
Name:SULLIVAN, JOHN PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PATRICK
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12670 WHITEHALL DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3619
Mailing Address - Country:US
Mailing Address - Phone:239-936-3554
Mailing Address - Fax:239-936-8993
Practice Address - Street 1:12670 WHITEHALL DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3619
Practice Address - Country:US
Practice Address - Phone:239-936-3554
Practice Address - Fax:239-936-8993
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4313122084N0400X
FLME 1256932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15768800Medicaid
PA1019108090001Medicaid
FL15768800Medicaid
PASU117339HFAMedicare PIN