Provider Demographics
NPI:1124311360
Name:SULLIVAN, MALLORY (DO)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WATERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13480-1165
Mailing Address - Country:US
Mailing Address - Phone:315-841-4178
Mailing Address - Fax:315-841-4338
Practice Address - Street 1:117 W MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WATERVILLE
Practice Address - State:NY
Practice Address - Zip Code:13480-1165
Practice Address - Country:US
Practice Address - Phone:315-841-4178
Practice Address - Fax:315-841-4338
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY274601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine