Provider Demographics
NPI:1861426413
Name:SULLIVAN, JAY FREDERICK (MD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:FREDERICK
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 1:4882B NORTH JEFFERSON STREET
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142
Mailing Address - Country:US
Mailing Address - Phone:315-298-2768
Mailing Address - Fax:315-298-2846
Practice Address - Street 1:4882B NORTH JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:NY
Practice Address - Zip Code:13142
Practice Address - Country:US
Practice Address - Phone:315-298-2768
Practice Address - Fax:315-298-2846
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169461207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000006298OtherRMSCO
169461-1WOtherWORKER'S COMPENSATION
5900753OtherGHI
NY01538238Medicaid
CC6514OtherMEDICARE
799222OtherAETNA HMO
161577435OtherPOMCO
5939163OtherAETNA NON HMO
000006298OtherBCBS
080155488OtherMEDICARE RAILROAD
138562OtherCIGNA
00020708301OtherUNIVERA
691259OtherMVP
799222OtherAETNA HMO