Provider Demographics
NPI:1235214503
Name:MCCULLOUGH, ROBERT W (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 W MILL ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3572
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:137 W MILL ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3572
Practice Address - Country:US
Practice Address - Phone:770-471-5037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA836-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000178032A1Medicaid
GA52146571OtherBLUE CROSS/BLUE SHIELD
GA0164140001Medicare NSC
GA55450254SAMedicare PIN