Provider Demographics
NPI:1558756262
Name:SULLIVAN, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 AMGEN CENTER DR
Mailing Address - Street 2:38-4-C
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-1730
Mailing Address - Country:US
Mailing Address - Phone:805-447-4429
Mailing Address - Fax:
Practice Address - Street 1:1 AMGEN CENTER DR
Practice Address - Street 2:38-4-C
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-1730
Practice Address - Country:US
Practice Address - Phone:805-447-4429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50369207R00000X, 207RA0401X, 208U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No208U00000XAllopathic & Osteopathic PhysiciansClinical Pharmacology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC89922Medicare UPIN