Provider Demographics
NPI:1306303458
Name:SULLIVAN, COLTEN BRIAR (DPT)
Entity type:Individual
Prefix:
First Name:COLTEN
Middle Name:BRIAR
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4143
Mailing Address - Country:US
Mailing Address - Phone:919-797-9588
Mailing Address - Fax:
Practice Address - Street 1:1019 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4143
Practice Address - Country:US
Practice Address - Phone:919-797-9588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP18599208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP18599OtherLICENSE NUMBER