Provider Demographics
NPI:1417691676
Name:MCCULLEY, CHARLOT MITCHELL
Entity Type:Individual
Prefix:
First Name:CHARLOT
Middle Name:MITCHELL
Last Name:MCCULLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-1088
Mailing Address - Country:US
Mailing Address - Phone:918-549-5256
Mailing Address - Fax:
Practice Address - Street 1:3100 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-1088
Practice Address - Country:US
Practice Address - Phone:918-549-5256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist