Provider Demographics
NPI:1356355531
Name:SULLIVAN, JOHN PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PAUL
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 1:4011 GARDINER POINT DR STE 101
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1988
Mailing Address - Country:US
Mailing Address - Phone:502-451-5121
Mailing Address - Fax:502-451-5125
Practice Address - Street 1:4011 GARDINER POINT DR STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1988
Practice Address - Country:US
Practice Address - Phone:502-451-5121
Practice Address - Fax:502-451-5125
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY217042084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64217045Medicaid
IN100012920AMedicaid
KYC65098Medicare UPIN
KY64217045Medicaid