Basic Information
| Provider Information | |||||||||
| NPI: | 1497701130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | CARY | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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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: | 300 N THORNTON ST. | ||||||||
| Address2: | |||||||||
| City: | VIAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749620446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187735228 | ||||||||
| FaxNumber: | 9187738482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 03/27/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2148 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 731153208003 | 01 | OK | BLUE CROSS BLUE SHIELD | OTHER | 100254810G | 05 | OK | MEDICAID | 100254810E | 05 | OK | MEDICAID |