Provider Demographics
NPI:1558709089
Name:MCCULLEY, CAROLINE BONAFEDE (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLINE
Middle Name:BONAFEDE
Last Name:MCCULLEY
Suffix:
Gender:F
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 540
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-215-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPG163166390200000X
ORMD171396207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program