Provider Demographics
NPI:1396984894
Name:SULLIVAN, JAY CUMMINGS (DO)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:CUMMINGS
Last Name:SULLIVAN
Suffix:
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 1:3722 74TH AVENUE CT NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-6446
Mailing Address - Country:US
Mailing Address - Phone:253-682-8002
Mailing Address - Fax:
Practice Address - Street 1:3722 74TH AVENUE CT NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-6446
Practice Address - Country:US
Practice Address - Phone:253-682-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-07
Last Update Date:2009-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA20A6641207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine