Provider Demographics
NPI:1558542779
Name:MCCULLOUGH, KATHRYN M (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:M
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1525 LARKSPUR PL
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6976
Mailing Address - Country:US
Mailing Address - Phone:662-840-4624
Mailing Address - Fax:662-840-9426
Practice Address - Street 1:3929 N GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-0915
Practice Address - Country:US
Practice Address - Phone:662-840-4624
Practice Address - Fax:662-840-9426
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS483152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03888791Medicaid