Provider Demographics
NPI:1487736377
Name:SULLIVAN, WILLIAM M (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:29 HUNTS POINT RD
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-2926
Mailing Address - Country:US
Mailing Address - Phone:207-799-0457
Mailing Address - Fax:
Practice Address - Street 1:144 STATE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3776
Practice Address - Country:US
Practice Address - Phone:207-799-0457
Practice Address - Fax:207-799-0457
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME123212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MED08920Medicare UPIN
MEMM2665Medicare ID - Type Unspecified