Provider Demographics
NPI:1871563551
Name:SULLIVAN, JAMES DENNIS (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DENNIS
Last Name:SULLIVAN
Suffix:
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 1:600 NORTHERN BLVD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5200
Mailing Address - Country:US
Mailing Address - Phone:516-487-9454
Mailing Address - Fax:516-487-2745
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:SUITE 111
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5200
Practice Address - Country:US
Practice Address - Phone:516-487-9454
Practice Address - Fax:516-487-2745
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176543174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01839674Medicaid
NY01839674Medicaid
NY42H461Medicare ID - Type Unspecified