Provider Demographics
NPI:1740585843
Name:SULLIVAN, TERRY (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
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 1:11671 BACA RD
Mailing Address - Street 2:
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433-7522
Mailing Address - Country:US
Mailing Address - Phone:720-331-8553
Mailing Address - Fax:
Practice Address - Street 1:11671 BACA RD
Practice Address - Street 2:
Practice Address - City:CONIFER
Practice Address - State:CO
Practice Address - Zip Code:80433-7522
Practice Address - Country:US
Practice Address - Phone:720-331-8553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22560207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine