Provider Demographics
NPI:1306264890
Name:SULLIVAN, KEVIN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
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 1:2021 PERDIDO ST FL 8
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-1352
Mailing Address - Country:US
Mailing Address - Phone:504-568-4750
Mailing Address - Fax:
Practice Address - Street 1:2021 PERDIDO ST FL 8
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-1352
Practice Address - Country:US
Practice Address - Phone:504-568-4750
Practice Address - Fax:504-568-2202
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3402982086X0206X
CAA171748208600000X
WAML60475569208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery