Provider Demographics
NPI:1578554291
Name:MCCULLUM, SUSAN D (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:MCCULLUM
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 1357
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-1357
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:239-278-3857
Practice Address - Street 1:2232 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-3717
Practice Address - Country:US
Practice Address - Phone:239-344-2341
Practice Address - Fax:239-334-7518
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86366208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265855100Medicaid
FL7768378OtherAETNA
FL1483313OtherUNITED
FL62808OtherBLUE CROSS
FL62808ZMedicare PIN
FL7768378OtherAETNA