Provider Demographics
NPI:1982691689
Name:SULLIVAN, JOSEPH WYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:WYNN
Last Name:SULLIVAN
Suffix:
Gender:M
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:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:600 ZEAGLER DR
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3811
Practice Address - Country:US
Practice Address - Phone:386-325-8140
Practice Address - Fax:386-325-8848
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5691207RX0202X
FLOS 5691207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80404OtherBCBS
FLP01593279OtherRR MEDICARE
FL064451000Medicaid
FLP0026501OtherFLORIDA HEALTHCARE PLUS
FL208804OtherAVMED
FLP01327657OtherRR MEDICARE
FL4473165OtherAETNA
FL4663165OtherAETNA
FL4663165OtherAETNA
FL208804OtherAVMED
FL1193481OtherWELLCARE
FL4663165OtherAETNA
FL80404OtherBCBS
FLP0026501OtherFLORIDA HEALTHCARE PLUS
FLF36843Medicare UPIN
FL80404RMedicare PIN
FL80404VMedicare PIN
FL1679440OtherBCBS
FL064451000Medicaid
FL80404QMedicare PIN