Provider Demographics
NPI:1376524611
Name:SULLIVAN, TIMOTHY JOSEPH (MD)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOSEPH
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 1:7711 W WALIN LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68532-9200
Mailing Address - Country:US
Mailing Address - Phone:402-742-2502
Mailing Address - Fax:402-817-1245
Practice Address - Street 1:1336 W A STE A
Practice Address - Street 2:CODDINGTON MEDICAL FAMILY PRACTICE
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68522-1231
Practice Address - Country:US
Practice Address - Phone:402-438-0101
Practice Address - Fax:402-817-1245
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17443207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEE28260Medicare UPIN
NE090459Medicare ID - Type Unspecified