Provider Demographics
NPI:1992716997
Name:SULLIVAN, DREW (MD)
Entity type:Individual
Prefix:
First Name:DREW
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 1:400 RACE ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3518
Mailing Address - Country:US
Mailing Address - Phone:408-278-3000
Mailing Address - Fax:
Practice Address - Street 1:625 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-3705
Practice Address - Country:US
Practice Address - Phone:408-278-3310
Practice Address - Fax:408-278-3378
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG322742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G322740Medicaid
CAA45081Medicare UPIN
CA00G322740Medicaid