Provider Demographics
NPI:1770872319
Name:SULLIVAN, MARY-MARIE AUSTIN (MD)
Entity type:Individual
Prefix:
First Name:MARY-MARIE
Middle Name:AUSTIN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY-MARIE
Other - Middle Name:
Other - Last Name:AUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-341-5200
Mailing Address - Fax:
Practice Address - Street 1:1134 N 500 W STE 102
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5569
Practice Address - Country:US
Practice Address - Phone:801-341-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8380179-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine