Provider Demographics
NPI:1841292562
Name:SULLIVAN, MITCHELL (MD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
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:PO BOX 83
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05851-0083
Mailing Address - Country:US
Mailing Address - Phone:802-748-9501
Mailing Address - Fax:802-748-3420
Practice Address - Street 1:195 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:LYNDONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05851-4511
Practice Address - Country:US
Practice Address - Phone:802-748-9501
Practice Address - Fax:802-748-3420
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9367207Q00000X
VT042-0012982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH160094OtherCIGNA HEALTHCARE
NH0106084YPNH01OtherANTHEM BC/BS
5830418OtherAETNA GROUP
NH9367OtherSTATE LICENSE #
NH30008999Medicaid
930044719OtherRAILROAD MEDICARE
NH3073723Medicaid
NH3073723Medicaid
BX5785Medicare PIN
NH160094OtherCIGNA HEALTHCARE
G12354Medicare UPIN