Provider Demographics
NPI:1720056393
Name:SULLIVAN, THOMAS P (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:WI
Mailing Address - Zip Code:53555-1464
Mailing Address - Country:US
Mailing Address - Phone:608-592-3296
Mailing Address - Fax:
Practice Address - Street 1:160 VALLEY DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:WI
Practice Address - Zip Code:53555-1464
Practice Address - Country:US
Practice Address - Phone:608-592-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19926207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI080075917OtherRAILROAD MEDICARE
WI31037600Medicaid
WI080075917OtherRAILROAD MEDICARE
000657120Medicare PIN
001057065Medicare PIN
WI31037600Medicaid
000513018Medicare PIN