Individual
SCOT A SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
10305 SW PARK WAY STE 203, PORTLAND, OR 97225-5033
(503) 223-8333
(503) 595-8160
Mailing address
10305 SW PARK WAY STE 203, PORTLAND, OR 97225-5033
(503) 223-8333
(503) 595-8160
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
20157
OK
207W00000X
Ophthalmology Physician
Primary
MD21723
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100102160B
—
OK
01
—
134409
GROUP PIN
OR
Enumeration date
03/18/2006
Last updated
09/17/2021
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