Provider Demographics
NPI:1356312771
Name:MCCULLOUGH, JACQUELINE MARY (MS RD CDN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARY
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MS RD CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2470 BOSTON POST RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-1467
Mailing Address - Country:US
Mailing Address - Phone:203-407-2500
Mailing Address - Fax:203-407-5812
Practice Address - Street 1:2200 WHITNEY AVE
Practice Address - Street 2:SUITE 180
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3691
Practice Address - Country:US
Practice Address - Phone:203-407-2500
Practice Address - Fax:203-407-5812
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000730207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT710000183Medicare ID - Type Unspecified