Provider Demographics
NPI:1124107081
Name:SULLIVAN, JOHN JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JAMES
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 1:688 VILLA WAY
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-5400
Mailing Address - Country:US
Mailing Address - Phone:707-822-9691
Mailing Address - Fax:
Practice Address - Street 1:525 2ND ST
Practice Address - Street 2:#300
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-5107
Practice Address - Country:US
Practice Address - Phone:707-445-0893
Practice Address - Fax:707-444-2563
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37184208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA46987Medicare UPIN