Provider Demographics
NPI:1649272956
Name:HOFF-SULLIVAN, EMILY (MD)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:HOFF-SULLIVAN
Suffix:
Gender:F
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:PO BOX 17543
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-7543
Mailing Address - Country:US
Mailing Address - Phone:904-399-3150
Mailing Address - Fax:904-399-3515
Practice Address - Street 1:2820 GIBSON RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-4804
Practice Address - Country:US
Practice Address - Phone:904-399-3150
Practice Address - Fax:904-399-3515
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043649174400000X
FLME0073341174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA162188000OtherUS DOL
GA00772912AMedicaid
FL41456OtherBCBS
GA200027956OtherRR MEDICARE
GA4299040001OtherDME
GA200027956OtherRR MEDICARE
GA20BBDGKMedicare ID - Type Unspecified
GA00772912AMedicaid