Provider Demographics
NPI:1275605768
Name:MCCULLOUGH, JOHN JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JEFFREY
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:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE STREET SE, MMC 609
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-0622
Mailing Address - Fax:612-626-2696
Practice Address - Street 1:420 DELAWARE STREET SE, ROOM 760
Practice Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-626-0622
Practice Address - Fax:612-626-2696
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19412207ZB0001X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Not Answered207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34601900Medicaid
11-74546OtherMEDICA PRIMARY
IA0513234Medicaid
101363OtherUCARE
768254OtherARAZ
1009234OtherPREFERRED ONE
HP22294OtherHEALTH PARTNERS
1122551OtherMEDICA CHOICE
2T225MCOtherBLUE CROSS BLUE SHIELD
B58543Medicare UPIN