Provider Demographics
NPI:1427296375
Name:SULLIVAN, JOSEPH M (DPM)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2144 CAPEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUDDLESTON
Mailing Address - State:VA
Mailing Address - Zip Code:24104-3430
Mailing Address - Country:US
Mailing Address - Phone:540-904-8661
Mailing Address - Fax:
Practice Address - Street 1:2144 CAPEWOOD DR
Practice Address - Street 2:
Practice Address - City:HUDDLESTON
Practice Address - State:VA
Practice Address - Zip Code:24104-3430
Practice Address - Country:US
Practice Address - Phone:540-904-8661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300735213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA480035217Medicare PIN
U87966Medicare UPIN
480000722Medicare PIN