Provider Demographics
NPI:1992795686
Name:SULLIVAN, DENNIS M (MD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:M
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:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:NATURAL BRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:13665-0159
Mailing Address - Country:US
Mailing Address - Phone:315-644-4535
Mailing Address - Fax:
Practice Address - Street 1:CTMC
Practice Address - Street 2:US ARMY MEDDAC
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-8437
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166641207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN