Provider Demographics
NPI:1407849144
Name:MCCULLOUGH, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1739 SCHERTZ PKWY
Mailing Address - Street 2:
Mailing Address - City:SCHERTZ
Mailing Address - State:TX
Mailing Address - Zip Code:78154-1639
Mailing Address - Country:US
Mailing Address - Phone:210-491-8179
Mailing Address - Fax:210-590-2664
Practice Address - Street 1:1739 SCHERTZ PKWY
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154-1639
Practice Address - Country:US
Practice Address - Phone:210-491-8179
Practice Address - Fax:210-590-2664
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127591906OtherWELLMED MEDICAID
TX347313YPL5OtherWELLMED MEDICARE
TX347313YPL5OtherWELLMED MEDICARE