Provider Demographics
NPI:1194807719
Name:SULLIVAN, MAURICE J (MD)
Entity type:Individual
Prefix:
First Name:MAURICE
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 HEYMANN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2616
Mailing Address - Country:US
Mailing Address - Phone:337-289-8717
Mailing Address - Fax:337-289-8718
Practice Address - Street 1:461 HEYMANN BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2616
Practice Address - Country:US
Practice Address - Phone:337-289-8717
Practice Address - Fax:337-289-8718
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2025-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11581207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1128554Medicaid
B65712Medicare UPIN
LA1128554Medicaid