Provider Demographics
NPI:1528047586
Name:SULLIVAN, JASON MURRAY (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:MURRAY
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:668 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3951
Mailing Address - Country:US
Mailing Address - Phone:731-424-2414
Mailing Address - Fax:731-424-4444
Practice Address - Street 1:668 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3951
Practice Address - Country:US
Practice Address - Phone:731-424-2414
Practice Address - Fax:731-424-4444
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0031354207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3838587Medicaid
TN3838587Medicaid
G89664Medicare UPIN