Provider Demographics
NPI:1780796003
Name:SULKOWSKI, VIKTOR P (MD)
Entity type:Individual
Prefix:DR
First Name:VIKTOR
Middle Name:P
Last Name:SULKOWSKI
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 1:3101 BROWNS MILL RD STE 6 PMB 386
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4100
Mailing Address - Country:US
Mailing Address - Phone:423-854-0001
Mailing Address - Fax:423-854-0002
Practice Address - Street 1:10461 WALLACE ALLEY ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-3936
Practice Address - Country:US
Practice Address - Phone:423-279-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000010318174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4051152OtherBCBS TN PROVIDER NUMBER
TN4051167OtherBCBS TN GRP PROVIDER NUMB
TN3379190Medicaid
TN3379190Medicaid
TN4051167OtherBCBS TN GRP PROVIDER NUMB
TN3878839Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER