Provider Demographics
NPI:1619182862
Name:CULLEN, BENJAMIN (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:CULLEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1520
Mailing Address - Country:US
Mailing Address - Phone:636-528-8686
Mailing Address - Fax:636-528-3332
Practice Address - Street 1:1175 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1520
Practice Address - Country:US
Practice Address - Phone:636-528-8686
Practice Address - Fax:636-528-3332
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011006590208600000X
MI5101016896208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery