Provider Demographics
NPI:1437140472
Name:SULLIVAN, LEO P (MD)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:P
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4401 MIDDLE SETTLEMENT ROAD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413
Mailing Address - Country:US
Mailing Address - Phone:315-797-3430
Mailing Address - Fax:315-624-7383
Practice Address - Street 1:4401 MIDDLE SETTLEMENT ROAD
Practice Address - Street 2:SUITE 208
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413
Practice Address - Country:US
Practice Address - Phone:315-797-3430
Practice Address - Fax:315-624-7383
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY165823-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01134596Medicaid
NYD91987Medicare UPIN
TH37092FMedicare PIN