Provider Demographics
NPI:1740300094
Name:SULLIVAN, GARRETT GRAY (MD)
Entity type:Individual
Prefix:DR
First Name:GARRETT
Middle Name:GRAY
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 1:2800 W 51ST ST
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66205-1747
Mailing Address - Country:US
Mailing Address - Phone:913-626-0254
Mailing Address - Fax:913-624-9601
Practice Address - Street 1:2800 W 51ST ST
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:KS
Practice Address - Zip Code:66205-1747
Practice Address - Country:US
Practice Address - Phone:913-626-0254
Practice Address - Fax:913-624-9601
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-33297208D00000X, 207Q00000X
MO2014012167207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine