Basic Information
| Provider Information | |||||||||
| NPI: | 1902901648 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLO | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 LINDEN OAKS | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146252839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853814982 | ||||||||
| FaxNumber: | 5853811821 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 LINDEN OAKS | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146252839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853814982 | ||||||||
| FaxNumber: | 5853811821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 222201 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02180298 | 05 | NY | MEDICAID | P010222201 | 01 | EXCELLUS BLUE CHOICEE | OTHER | 7216284 | 01 | AETNA US HEALTHCARE | OTHER | MDG382 | 01 | NY | PREFERRED CARE | OTHER | P020222201 | 01 | NY | BLUE SHIELD OF ROCHESTER | OTHER | RC60222201 | 01 | POMCO | OTHER | 782549 | 01 | NY | MVP UPSTATE DHP | OTHER |