Provider Demographics
NPI:1508126871
Name:CULLOM, GABRIEL A
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:A
Last Name:CULLOM
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 1:2328 E 40TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50317-5624
Mailing Address - Country:US
Mailing Address - Phone:515-422-0606
Mailing Address - Fax:
Practice Address - Street 1:2328 E 40TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50317-5624
Practice Address - Country:US
Practice Address - Phone:515-422-0606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3343344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi