Provider Demographics
NPI:1346237856
Name:CULBERTSON, CASEY (MD)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:CULBERTSON
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 1:747 52ND ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1809
Mailing Address - Country:US
Mailing Address - Phone:510-428-3294
Mailing Address - Fax:510-428-3381
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:510-428-3294
Practice Address - Fax:510-428-3381
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG605562080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G605560Medicaid