Provider Demographics
NPI:1780619890
Name:SULLIVAN, KEVIN JEREMIAH (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JEREMIAH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4700 POINT FOSDICK DR NW
Mailing Address - Street 2:STE 202
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1706
Mailing Address - Country:US
Mailing Address - Phone:253-858-9192
Mailing Address - Fax:253-857-1489
Practice Address - Street 1:4700 POINT FOSDICK DR NW
Practice Address - Street 2:STE 202
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1706
Practice Address - Country:US
Practice Address - Phone:253-858-9192
Practice Address - Fax:253-857-1489
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00037591207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA080144712OtherRAILROAD
WA0131075OtherSTATE L&I
WA8243149Medicaid
WA8928703OtherSTATE CRIME VICTIMS
WA0131075OtherSTATE L&I
WA8243149Medicaid