Provider Demographics
NPI:1497722219
Name:CULLEN, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
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 1:7 MARSH BROOK DR STE 205
Mailing Address - Street 2:
Mailing Address - City:SOMERSWORTH
Mailing Address - State:NH
Mailing Address - Zip Code:03878-6523
Mailing Address - Country:US
Mailing Address - Phone:603-742-2007
Mailing Address - Fax:
Practice Address - Street 1:67 CORPORATE DR, 2ND FL
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801
Practice Address - Country:US
Practice Address - Phone:603-810-8078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH19638207XX0005X, 207XX0005X
GA043191207XX0005X
ORMD160656207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3117862Medicaid
NH3117862Medicaid
5967224OtherAETNA
OR1497722219Medicaid
OR1497722219Medicaid
GA000773473BMedicaid