Provider Demographics
NPI:1023012911
Name:SULLIVAN, TIMOTHY JOHN III (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:SULLIVAN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 HARRISON BLVD.
Mailing Address - Street 2:STE 4640
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3304
Mailing Address - Country:US
Mailing Address - Phone:801-387-4850
Mailing Address - Fax:801-387-4855
Practice Address - Street 1:4403 HARRISON BLVD.
Practice Address - Street 2:STE 4640
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3304
Practice Address - Country:US
Practice Address - Phone:801-387-4850
Practice Address - Fax:801-387-4855
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037913207KA0200X
UT8263858-1205207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00570996CMedicaid
GA00570996FMedicaid
GA03BDBQSMedicare PIN
GA00570996FMedicaid
D97768Medicare UPIN