Provider Demographics
NPI:1326191107
Name:SULLIVAN, PAMELA C (MD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:C
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-2952
Mailing Address - Country:US
Mailing Address - Phone:585-872-2273
Mailing Address - Fax:
Practice Address - Street 1:7755 CENTER AVE STE 630
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647
Practice Address - Country:US
Practice Address - Phone:657-237-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188059207P00000X, 207R00000X
AZ59371207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY930079485OtherRAILROAD MEDICARE
NY02089325Medicaid
NYJ400051556/GRPBA0017Medicare PIN
NY930079485OtherRAILROAD MEDICARE
NYBB3434Medicare ID - Type Unspecified
NYJ400051557/GRP70008AMedicare PIN