Provider Demographics
NPI:1386805794
Name:SULLIVAN, LAURA E (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ELLEN
Other - Last Name:JACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1155 MILL ST # MSM14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-3901
Practice Address - Street 1:1500 E 2ND ST STE 400
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1198
Practice Address - Country:US
Practice Address - Phone:775-982-2400
Practice Address - Fax:775-982-2888
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17429207RC0000X, 207RC0000X
CAA153608207RC0000X
FLME152552207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114032200Medicaid
IN201226460Medicaid
IN558430159Medicare PIN