Provider Demographics
NPI:1801895834
Name:SULLIVAN, DANIEL JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOSEPH
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 1:1739 BEVERLY AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3593
Mailing Address - Country:US
Mailing Address - Phone:928-681-8565
Mailing Address - Fax:928-681-8564
Practice Address - Street 1:1739 BEVERLY AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3593
Practice Address - Country:US
Practice Address - Phone:928-681-8565
Practice Address - Fax:928-681-8564
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063476S207XS0117X
AZ38140207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ321301Medicaid
SU0722255Medicare ID - Type Unspecified
AZ321301Medicaid
AZZ123410Medicare PIN