Provider Demographics
NPI:1801874912
Name:SULLIVAN, DEBORAH A (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
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:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-0040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:78 SUTTON AVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MA
Practice Address - Zip Code:01540-1813
Practice Address - Country:US
Practice Address - Phone:508-499-1760
Practice Address - Fax:508-499-1757
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA152778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0434209010OtherAETNA
0434209010OtherCOMMONWEALTH IDENTITY
35293OtherFULLER COMMUNITY HEALTH
71913OtherHARVARD PILGRIM HEALTH
987228OtherNETWORK HEALTH
152778OtherTUFTS HEALTH PLAN
MA3179346Medicaid
71913OtherHARVARD PILGRIM HEALTH
G75071Medicare UPIN