Provider Demographics
NPI:1598749467
Name:MCCULLEM, ROBYN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBYN
Middle Name:MARIE
Last Name:MCCULLEM
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 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110
Mailing Address - Country:US
Mailing Address - Phone:573-635-5264
Mailing Address - Fax:573-635-2156
Practice Address - Street 1:1241 WEST STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109
Practice Address - Country:US
Practice Address - Phone:573-556-7719
Practice Address - Fax:573-635-2156
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
FLME94433207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00635931OtherMEDICARE RAILROAD
MO1598749467Medicaid
MOCP9089OtherRAILROAD GROUP
MO1598749467Medicaid