Provider Demographics
NPI:1275540411
Name:MCCULLOUGH, LARRY LORENZO (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:LORENZO
Last Name:MCCULLOUGH
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:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-7042
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:400 HOSPITAL DR STE 210
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-2489
Practice Address - Country:US
Practice Address - Phone:903-654-1151
Practice Address - Fax:903-654-1158
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-057040-L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX418792401Medicaid
PA1253310Medicaid
IA05591OtherWELLMARK BC&BS IA
PA1253310Medicaid
F62906Medicare UPIN
IA05591OtherWELLMARK BC&BS IA