Individual
JOHN M SULLIVAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
802 W LAMPASAS ST, ENNIS, TX 75119-4500
(972) 878-4700
(972) 878-2238
Mailing address
802 W LAMPASAS ST, ENNIS, TX 75119-4500
(972) 878-4700
(972) 878-2238
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
K5708
TX
2086S0129X
Vascular Surgery Physician
K5708
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
138206115
—
TX
01
—
8A7520
MEDICARE PTAN
TX
Enumeration date
08/26/2005
Last updated
01/13/2010
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