Provider Demographics
NPI:1710041942
Name:CULLINAN, MARYLOUISE (MD)
Entity Type:Individual
Prefix:
First Name:MARYLOUISE
Middle Name:
Last Name:CULLINAN
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 1:9141 GRANT ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80229-4374
Mailing Address - Country:US
Mailing Address - Phone:303-522-4686
Mailing Address - Fax:303-980-0431
Practice Address - Street 1:9141 GRANT ST
Practice Address - Street 2:SUITE 125
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4374
Practice Address - Country:US
Practice Address - Phone:303-522-4686
Practice Address - Fax:303-980-0431
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25375207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01253756Medicaid
COC803448Medicare PIN
CO01253756Medicaid