Provider Demographics
NPI:1194782854
Name:SULLIVAN, LARA (MD)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:
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 1:14300 METCALF AVE
Mailing Address - Street 2:STE. 122
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-2987
Mailing Address - Country:US
Mailing Address - Phone:913-825-4700
Mailing Address - Fax:913-825-4701
Practice Address - Street 1:14300 METCALF AVE
Practice Address - Street 2:STE. 122
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-2987
Practice Address - Country:US
Practice Address - Phone:913-825-4700
Practice Address - Fax:913-825-4701
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0429414208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H49984Medicare UPIN