| Doctor Name: | GLEN S O'SULLIVAN |
| NPI Number: | 1972504652 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | A44219 |
| Business Practice Address: | 635 Lassen Ln Mount Shasta, CA - 960679003 |
| Business Phone Number: | 8666683597 |
| Business Fax Number: | 8663016641 |
| Mailing Address: | 635 Lassen Ln, MOUNT SHASTA |
| State: | CA |
| Postal Code: | 960679003 |
| Phone Number: | 8666683597 |
| Fax Number: | 8663016641 |
| NPI Enumeration Date: | 08/03/2005 |
| NPI Last Update Date: | 11/23/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | A44219 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |