Provider Demographics
NPI:1194245662
Name:SULLIVAN, KEVIN BRIAN (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:BRIAN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:970-640-5914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1194245662171000000X
CA20A18937207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider