Basic Information
| Provider Information | |||||||||
| NPI: | 1720022171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | KIYOE | ||||||||
| MiddleName: | WU | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., PH.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WU | ||||||||
| OtherFirstName: | QINGFANG | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | M.D., PH.D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12 PARKWAY RD | ||||||||
| Address2: | |||||||||
| City: | BRONXVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107083602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136362955 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 34 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068503894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038522000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 250272 | NY | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 69837 | CT | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.