Provider Demographics
NPI:1417064171
Name:MCCULLOUGH, TONYA LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:LEWIS
Last Name:MCCULLOUGH
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 1:820 E 67TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4611
Mailing Address - Country:US
Mailing Address - Phone:912-355-9818
Mailing Address - Fax:912-356-9878
Practice Address - Street 1:820 E 67TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4611
Practice Address - Country:US
Practice Address - Phone:912-355-9818
Practice Address - Fax:912-356-9878
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034016174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582095621OtherTAX ID
GA00553825BMedicaid
GA00553825BMedicaid
GA07BDCLLMedicare ID - Type Unspecified