Provider Demographics
NPI:1356309181
Name:CULLEN, PHYLLIS ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:ANNE
Last Name:CULLEN
Suffix:
Gender:F
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 1477
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96721-1477
Mailing Address - Country:US
Mailing Address - Phone:530-895-3287
Mailing Address - Fax:
Practice Address - Street 1:1437 KILAUEA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4200
Practice Address - Country:US
Practice Address - Phone:808-498-4160
Practice Address - Fax:808-498-4163
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32403208VP0014X
HIMD 17298208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G324030Medicaid
CAZZZ06195ZOtherMEDICARE GROUP PTAN
CA00G324032OtherMEDICARE INDIVIDUAL PTAN
CA1881883320OtherMEDICARE GROUP NPI
CAZZZ06195ZOtherMEDICARE GROUP PTAN