Provider Demographics
NPI:1447332952
Name:SULLIVAN, DENNIS JAMES JR (MD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:JAMES
Last Name:SULLIVAN
Suffix:JR
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:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:ODANAH
Mailing Address - State:WI
Mailing Address - Zip Code:54861-0250
Mailing Address - Country:US
Mailing Address - Phone:715-682-7133
Mailing Address - Fax:715-685-7848
Practice Address - Street 1:72718 MAPLE STREET
Practice Address - Street 2:
Practice Address - City:ODANAH
Practice Address - State:WI
Practice Address - Zip Code:54861-0250
Practice Address - Country:US
Practice Address - Phone:715-682-7133
Practice Address - Fax:715-685-7848
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42911208600000X
MN43063208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34021900Medicaid
WIG67720Medicare UPIN
WI34021900Medicaid
521813Medicare ID - Type Unspecified