Provider Demographics
NPI:1932176641
Name:SULLIVAN, SABRA (MD, PHD)
Entity Type:Individual
Prefix:
First Name:SABRA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MARSHALL ST
Mailing Address - Street 2:SUITE 606
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1651
Mailing Address - Country:US
Mailing Address - Phone:601-355-8555
Mailing Address - Fax:601-355-2244
Practice Address - Street 1:501 MARSHALL ST
Practice Address - Street 2:SUITE 606
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1651
Practice Address - Country:US
Practice Address - Phone:601-355-8555
Practice Address - Fax:601-355-2244
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14238207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0114928Medicaid
MS0114928Medicaid
MSF28566Medicare UPIN