Provider Demographics
NPI:1093786931
Name:MCCULLOUGH, WILLIAM T (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:T
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1101 RAINTREE CIR STE 120
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5292
Mailing Address - Country:US
Mailing Address - Phone:469-656-9041
Mailing Address - Fax:469-656-9046
Practice Address - Street 1:1101 RAINTREE CIR STE 120
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013
Practice Address - Country:US
Practice Address - Phone:214-817-9301
Practice Address - Fax:217-214-5948
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4201207T00000X, 207T00000X
MO112689207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34876700Medicaid
TX125193Medicare UPIN