Provider Demographics
NPI:1447288188
Name:SULLIVENT, ERNEST EUGENE III (MD)
Entity type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:EUGENE
Last Name:SULLIVENT
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:8034 EDGERTON DRIVE
Mailing Address - Street 2:SUITE 132
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840-2200
Mailing Address - Country:US
Mailing Address - Phone:719-333-7716
Mailing Address - Fax:719-333-3578
Practice Address - Street 1:8034 EDGERTON DRIVE
Practice Address - Street 2:SUITE 132
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2200
Practice Address - Country:US
Practice Address - Phone:719-333-7716
Practice Address - Fax:719-333-3578
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2018-07-19
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Provider Licenses
StateLicense IDTaxonomies
TXJ83862083P0901X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131177107Medicaid
TX8D0930Medicare ID - Type Unspecified
TX131177107Medicaid