Provider Demographics
NPI:1497798052
Name:CULLISON, TIMOTHY ALAN (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALAN
Last Name:CULLISON
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 1:52 LEAVER DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-9749
Mailing Address - Country:US
Mailing Address - Phone:509-216-2757
Mailing Address - Fax:
Practice Address - Street 1:60 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5980
Practice Address - Country:US
Practice Address - Phone:386-586-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL154277207L00000X, 207R00000X
IN01037584207L00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL154277OtherFLORIDA DEPARTMENT OF HEALTH
IN01037584OtherINDIANA MEDICAL BOARD
ID1107939Medicare PIN