Provider Demographics
NPI:1467439042
Name:CULLOM, ROBERT DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DOUGLAS
Last Name:CULLOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 KINGS WAY
Practice Address - Street 2:SUITE 1300
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2505
Practice Address - Country:US
Practice Address - Phone:757-345-3001
Practice Address - Fax:757-345-3102
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101057539207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1467439042Medicaid
VA180034978Medicare PIN
VA016250R53Medicare PIN
VA1467439042Medicaid