Provider Demographics
NPI:1770694499
Name:SULLIVAN, JOHN M (MD PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:175 KENTON PL
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-4309
Mailing Address - Country:US
Mailing Address - Phone:716-649-4785
Mailing Address - Fax:
Practice Address - Street 1:3495 BAILEY AVE
Practice Address - Street 2:BUILDING 20, MS151, VA WNY HEALTHCARE SYSTEM,
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1129
Practice Address - Country:US
Practice Address - Phone:716-862-6533
Practice Address - Fax:716-862-6526
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY207651207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology