Provider Demographics
NPI:1881749224
Name:OSULLIVAN, SEAN K (MD, DABR)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:K
Last Name:OSULLIVAN
Suffix:
Gender:M
Credentials:MD, DABR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 N. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904
Mailing Address - Country:US
Mailing Address - Phone:361-572-3139
Mailing Address - Fax:361-572-8610
Practice Address - Street 1:6915 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904
Practice Address - Country:US
Practice Address - Phone:361-572-3139
Practice Address - Fax:361-572-8610
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH64812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089859501Medicaid
TX089859501Medicaid
TXF33840Medicare UPIN