Provider Demographics
NPI:1275503864
Name:CULLOM, MARY ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:CULLOM
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11800 ROCK LANDING DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4206
Practice Address - Country:US
Practice Address - Phone:757-643-8800
Practice Address - Fax:757-643-8919
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2013-10-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101049366207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1275503864Medicaid
VA1275503864Medicaid
VA180036431Medicare PIN
VAE93224Medicare UPIN