Provider Demographics
NPI:1114064029
Name:MCCULLOCH, ALEXANDER T JR
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:T
Last Name:MCCULLOCH
Suffix:JR
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:AESTHETIC SURGERY CENTER OF COLORADO
Mailing Address - Street 2:5901 CORPORATE DRIVE
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919
Mailing Address - Country:US
Mailing Address - Phone:719-597-1200
Mailing Address - Fax:719-597-2333
Practice Address - Street 1:5901 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-1941
Practice Address - Country:US
Practice Address - Phone:719-597-1200
Practice Address - Fax:719-597-2333
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24965208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery