Provider Demographics
NPI:1306998406
Name:SULLIVAN, JERRY J (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:J
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 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:6501 LOISDALE CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-1826
Practice Address - Country:US
Practice Address - Phone:703-922-1000
Practice Address - Fax:703-922-1039
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017070207Q00000X
VA0101243402207Q00000X
MDD0071387207Q00000X
DCMD039385207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8103087Medicaid
WAG001050828Medicare PIN
WAG8871415Medicare PIN
WAE57807Medicare UPIN