Provider Demographics
NPI:1285775932
Name:SULLIVAN, TIMOTHY BERNARD (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BERNARD
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 MILLWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3701
Mailing Address - Country:US
Mailing Address - Phone:914-413-1957
Mailing Address - Fax:718-226-8144
Practice Address - Street 1:30 GLENN ST
Practice Address - Street 2:SUITE 305
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10603-3254
Practice Address - Country:US
Practice Address - Phone:914-413-1957
Practice Address - Fax:718-226-8144
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1351402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07F811Medicare ID - Type Unspecified
NYD34130Medicare UPIN