Provider Demographics
NPI:1710964754
Name:MCCULLOUCH, CHARLES LARRY JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LARRY
Last Name:MCCULLOUCH
Suffix:JR
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 1:1560 NORTH OLIVER ST.
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39739
Mailing Address - Country:US
Mailing Address - Phone:662-738-4424
Mailing Address - Fax:662-738-4615
Practice Address - Street 1:1560 NORTH OLIVER ST.
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39739
Practice Address - Country:US
Practice Address - Phone:662-738-4424
Practice Address - Fax:662-738-4615
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00147884OtherRAILROAD MEDICARE
MS00125739Medicaid
MS00125739Medicaid
P00147884OtherRAILROAD MEDICARE