Provider Demographics
NPI:1548280696
Name:SULLIVAN, DANIEL JOSEPH (DO)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOSEPH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1221 PLEASANT ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1423
Mailing Address - Country:US
Mailing Address - Phone:515-241-8223
Mailing Address - Fax:515-241-4313
Practice Address - Street 1:1221 PLEASANT ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1423
Practice Address - Country:US
Practice Address - Phone:515-241-8223
Practice Address - Fax:515-241-4313
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-03372207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1548280696Medicaid
IA1548280696Medicaid