Basic Information
| Provider Information | |||||||||
| NPI: | 1003862673 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | C. PATRICK SULLIVAN,DO | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 446 | ||||||||
| Address2: | |||||||||
| City: | VIAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749620446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187735228 | ||||||||
| FaxNumber: | 9187738482 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 NORTH THORNTON | ||||||||
| Address2: | |||||||||
| City: | VIAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749620446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187735228 | ||||||||
| FaxNumber: | 9187738482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | CARY | ||||||||
| AuthorizedOfficialMiddleName: | PATRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9187735228 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2148 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100254810E | 05 | OK | MEDICAID | 100254810G | 05 | OK | MEDICAID | 100757080G | 05 | OK | MEDICAID |