Provider Demographics
NPI:1023162559
Name:SULLIVAN, ANDRE JAWANN (MD)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:JAWANN
Last Name:SULLIVAN
Suffix:
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 1:325 MDG, 340 MAGNOLIA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:TYNDALL AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32403
Mailing Address - Country:US
Mailing Address - Phone:703-731-2566
Mailing Address - Fax:
Practice Address - Street 1:325 MDG, 340 MAGNOLIA CIRCLE
Practice Address - Street 2:
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403
Practice Address - Country:US
Practice Address - Phone:703-731-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41880101YP2500X
TXR94462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional