Provider Demographics
NPI:1316085160
Name:SULLIVAN, BART (MD)
Entity type:Individual
Prefix:DR
First Name:BART
Middle Name:
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 1:1221 SNOWBIRD DR
Mailing Address - Street 2:
Mailing Address - City:FRAZIER PARK
Mailing Address - State:CA
Mailing Address - Zip Code:93225-9693
Mailing Address - Country:US
Mailing Address - Phone:661-245-0135
Mailing Address - Fax:
Practice Address - Street 1:115 W E ST
Practice Address - Street 2:
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-1607
Practice Address - Country:US
Practice Address - Phone:661-822-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31288207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEN481ZMedicare PIN
A84190Medicare UPIN