Provider Demographics
NPI:1841619764
Name:SULLIVAN, COLIN A (MD)
Entity type:Individual
Prefix:DR
First Name:COLIN
Middle Name:A
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 1:2502 W SAINT ISABEL ST STE B
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6355
Mailing Address - Country:US
Mailing Address - Phone:813-874-5707
Mailing Address - Fax:
Practice Address - Street 1:6901 SIMMONS LOOP
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-9498
Practice Address - Country:US
Practice Address - Phone:813-302-8000
Practice Address - Fax:813-874-5908
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME130061207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine