Provider Demographics
NPI:1194112235
Name:SULLIVAN, ELIXABETH LASKURAIN (MD)
Entity type:Individual
Prefix:DR
First Name:ELIXABETH
Middle Name:LASKURAIN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 WALNUT ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4750
Mailing Address - Country:US
Mailing Address - Phone:703-246-9246
Mailing Address - Fax:
Practice Address - Street 1:3930 WALNUT ST STE 101
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4750
Practice Address - Country:US
Practice Address - Phone:703-246-9246
Practice Address - Fax:703-246-9257
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101268835207R00000X, 207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program