Provider Demographics
NPI:1679699052
Name:JONATHAN W. MCCULLOUGH, DCPC
Entity Type:Organization
Organization Name:JONATHAN W. MCCULLOUGH, DCPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-946-0444
Mailing Address - Street 1:35 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19054-3901
Mailing Address - Country:US
Mailing Address - Phone:215-946-0444
Mailing Address - Fax:215-946-0448
Practice Address - Street 1:35 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:PA
Practice Address - Zip Code:19054-3901
Practice Address - Country:US
Practice Address - Phone:215-946-0444
Practice Address - Fax:215-946-0448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC2206P204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========OtherEIN
PA=========OtherEIN