Provider Demographics
NPI:1164409488
Name:CULBERTSON, GARY RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:RANDALL
Last Name:CULBERTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-2403
Mailing Address - Country:US
Mailing Address - Phone:803-773-6361
Mailing Address - Fax:803-773-6009
Practice Address - Street 1:18 MILLER RD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2403
Practice Address - Country:US
Practice Address - Phone:803-773-6361
Practice Address - Fax:803-773-6009
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17109208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT11332Medicaid