Provider Demographics
NPI:1346240223
Name:SULLIVAN, JOAN M (MD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:M
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 1:102 HORIZON DR
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9791
Mailing Address - Country:US
Mailing Address - Phone:607-257-1014
Mailing Address - Fax:
Practice Address - Street 1:20 ARROWOOD DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1857
Practice Address - Country:US
Practice Address - Phone:607-266-7800
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186213173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine