Provider Demographics
NPI:1750361036
Name:SULLIVAN, VINCENT E (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:E
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 1:19878 SAINT JOSEPH DR
Mailing Address - Street 2:POST OFFICE BOX 160
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-8850
Mailing Address - Country:US
Mailing Address - Phone:641-437-1576
Mailing Address - Fax:641-437-4205
Practice Address - Street 1:19878 SAINT JOSEPH DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-8850
Practice Address - Country:US
Practice Address - Phone:641-437-1576
Practice Address - Fax:641-437-4205
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18213208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0186270Medicaid
IA0186270Medicaid
IAI15567Medicare ID - Type Unspecified