Provider Demographics
NPI:1679937353
Name:MCCULLOUGH, JAMES W (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:MCCULLOUGH
Suffix:
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 800022
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-0022
Mailing Address - Country:US
Mailing Address - Phone:800-953-0104
Mailing Address - Fax:303-765-6670
Practice Address - Street 1:729 E SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-3512
Practice Address - Country:US
Practice Address - Phone:719-547-9119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0067657208M00000X, 207Q00000X, 207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000183241Medicaid