Provider Demographics
NPI:1386676146
Name:CULLEN, GERALD MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:MICHAEL
Last Name:CULLEN
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 1:10335 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5763
Mailing Address - Country:US
Mailing Address - Phone:262-240-9870
Mailing Address - Fax:262-240-9869
Practice Address - Street 1:10400 W NORTH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-2425
Practice Address - Country:US
Practice Address - Phone:414-771-7470
Practice Address - Fax:414-771-7493
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19875-0202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31534400Medicaid
WI31534400Medicaid