Provider Demographics
NPI:1275832362
Name:MICHAEL R. MCCULLOUGH, D.O., P.A.
Entity Type:Organization
Organization Name:MICHAEL R. MCCULLOUGH, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-988-1588
Mailing Address - Street 1:643 S GREAT SOUTHWEST PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1056
Mailing Address - Country:US
Mailing Address - Phone:972-602-0615
Mailing Address - Fax:
Practice Address - Street 1:643 S GREAT SOUTHWEST PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1056
Practice Address - Country:US
Practice Address - Phone:972-602-0615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9682207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033519201Medicaid
TX033519201Medicaid