Provider Demographics
NPI:1275619603
Name:CULL, CHARLES CODY (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CODY
Last Name:CULL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 NAVAJO LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-3283
Mailing Address - Country:US
Mailing Address - Phone:702-596-5589
Mailing Address - Fax:725-205-4844
Practice Address - Street 1:1717 NAVAJO LAKE WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-3283
Practice Address - Country:US
Practice Address - Phone:702-596-5589
Practice Address - Fax:725-205-4844
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1201213E00000X
IN07000745A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100407460Medicaid
IN07000745COtherCONTROLLED SUBSTANCE #
IN100407460Medicaid
IN138320Medicare PIN
IN5859210001Medicare NSC