Provider Demographics
NPI:1861515231
Name:SULLIVAN, SHANNON (M D)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 BROADWAY ST
Mailing Address - Street 2:MAIL CODE 5704
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-3132
Mailing Address - Country:US
Mailing Address - Phone:650-723-6601
Mailing Address - Fax:
Practice Address - Street 1:450 BROADWAY ST
Practice Address - Street 2:MAIL CODE 5704
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3132
Practice Address - Country:US
Practice Address - Phone:650-723-6601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81983208000000X, 2080P0214X, 2080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA81983OtherCA MEDICAL LICENSE