Individual
DR. FRED M SULLIVAN JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1501 KINGS HWY, SHREVEPORT, LA 71103-4228
(318) 675-5000
Mailing address
1512 W KIRBY PL, SHREVEPORT, LA 71103-3822
(318) 675-7636
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
016881
LA
208000000X
Pediatrics Physician
Primary
016881
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1345261
—
LA
01
—
5M257F600
MEDICARE - PTAN
LA
Enumeration date
09/16/2006
Last updated
05/15/2012
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