Provider Demographics
NPI:1043581812
Name:REILLY, CULLAN ROBERT (DPM)
Entity Type:Individual
Prefix:DR
First Name:CULLAN
Middle Name:ROBERT
Last Name:REILLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:704-216-5633
Mailing Address - Fax:704-639-0785
Practice Address - Street 1:810 MITCHELL AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-6253
Practice Address - Country:US
Practice Address - Phone:704-216-5633
Practice Address - Fax:704-639-0785
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC592213E00000X, 213ES0103X
ILBL8403747-WR1120213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist