Provider Demographics
NPI:1043494123
Name:CULLEN, ANDREW M
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:M
Last Name:CULLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25301 ROCKAWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3113
Mailing Address - Country:US
Mailing Address - Phone:516-295-2135
Mailing Address - Fax:516-295-4561
Practice Address - Street 1:25301 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3113
Practice Address - Country:US
Practice Address - Phone:516-295-2135
Practice Address - Fax:516-295-4561
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-25
Last Update Date:2007-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006356-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00724910Medicaid