Provider Demographics
NPI:1073713376
Name:MICHAEL L. MCCULLOUGH MD PA
Entity Type:Organization
Organization Name:MICHAEL L. MCCULLOUGH MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-265-8646
Mailing Address - Street 1:8411 PRESTON RD
Mailing Address - Street 2:#200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-5523
Mailing Address - Country:US
Mailing Address - Phone:214-265-8646
Mailing Address - Fax:214-361-1939
Practice Address - Street 1:8411 PRESTON RD
Practice Address - Street 2:#200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-5523
Practice Address - Country:US
Practice Address - Phone:214-265-8646
Practice Address - Fax:214-361-1939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD0965207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC19109Medicare UPIN