Provider Demographics
NPI:1710997135
Name:CULLOM, EDWARD THOMAS III (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:THOMAS
Last Name:CULLOM
Suffix:III
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 1:1029 RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9554
Mailing Address - Country:US
Mailing Address - Phone:601-664-1000
Mailing Address - Fax:601-664-2777
Practice Address - Street 1:1029 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9554
Practice Address - Country:US
Practice Address - Phone:601-664-1000
Practice Address - Fax:601-664-2777
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11803207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05883835Medicaid
MS01409383Medicaid
MS05883835Medicaid
MS01409383Medicaid
MS512I140021Medicare PIN