Provider Demographics
NPI:1528387958
Name:SULLIVAN, JONATHAN M (DPM)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1890 LPGA BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7131
Mailing Address - Country:US
Mailing Address - Phone:386-274-3336
Mailing Address - Fax:386-274-3660
Practice Address - Street 1:11 FLORIDA PARK DR N
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3866
Practice Address - Country:US
Practice Address - Phone:386-445-4734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003666213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H218190Medicare PIN