Provider Demographics
NPI:1811300890
Name:SULLIVAN, JAMIE (DO)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-737-7000
Mailing Address - Fax:
Practice Address - Street 1:1405 S COUNTY TRL STE 510
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-5097
Practice Address - Country:US
Practice Address - Phone:401-736-4570
Practice Address - Fax:401-921-6931
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP03135390200000X
RIDO00846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program