Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207KA0200X | Allergist | 037913 | GA |
Y | 207KA0200X | Allergist | 8263858-1205 | UT |
NPI | 1023012911 |
---|---|
Provider Name | Dr. Timothy John Sullivan III |
First Address | Ogden, UT 84403-3304 |
Second Address | Ogden, UT 84403-3304 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2005 |
Last Update Date | 03/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00570996C | (05) | GA |
00570996F | (05) | GA |
D97768 | (02) |