Provider Demographics
NPI:1043903412
Name:SULLIVAN, JOSEPH
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 HELKE RD
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-1504
Mailing Address - Country:US
Mailing Address - Phone:937-620-2301
Mailing Address - Fax:
Practice Address - Street 1:5563 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2225
Practice Address - Country:US
Practice Address - Phone:937-291-2300
Practice Address - Fax:937-291-2303
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty