Provider Demographics
NPI:1568410181
Name:MCCULLOCH, GARY LEE SR (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:MCCULLOCH
Suffix:SR
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:PO BOX 241120
Mailing Address - Street 2:
Mailing Address - City:ECLECTIC
Mailing Address - State:AL
Mailing Address - Zip Code:36024
Mailing Address - Country:US
Mailing Address - Phone:334-541-3020
Mailing Address - Fax:334-541-3109
Practice Address - Street 1:575 CLAUD RD
Practice Address - Street 2:
Practice Address - City:ECLECTIC
Practice Address - State:AL
Practice Address - Zip Code:36024-6318
Practice Address - Country:US
Practice Address - Phone:334-541-3020
Practice Address - Fax:334-541-3109
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12809207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000099530Medicare ID - Type Unspecified
C72579Medicare UPIN