Provider Demographics
NPI:1972533933
Name:SULLIVAN, DAVID RYAN (DPM)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RYAN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16411 SOUTHPARK DR.
Mailing Address - Street 2:SUITE B
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074
Mailing Address - Country:US
Mailing Address - Phone:317-896-6655
Mailing Address - Fax:317-896-6081
Practice Address - Street 1:16411 SOUTHPARK DR.
Practice Address - Street 2:SUITE B
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074
Practice Address - Country:US
Practice Address - Phone:317-896-6655
Practice Address - Fax:317-896-6081
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001049A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist