Provider Demographics
NPI:1700892437
Name:SULLIVAN, LAURA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name: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 1:7316 S. SETTLER DR.
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:CO
Mailing Address - Zip Code:80465
Mailing Address - Country:US
Mailing Address - Phone:714-722-4688
Mailing Address - Fax:562-920-4642
Practice Address - Street 1:7316 S. SETTLER DR.
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:CO
Practice Address - Zip Code:80465
Practice Address - Country:US
Practice Address - Phone:714-722-4688
Practice Address - Fax:562-904-8095
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55298207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G552980OtherBLUE SHIELD
CA00G552980Medicaid
CA00G952980Medicaid
CA110227243OtherMEDICARE RAILROAD
CA110227243OtherRAILROAD MEDICARE
CA00G552980OtherBLUE SHIELD
CA00G552980Medicaid