Provider Demographics
NPI:1710999123
Name:MCCULLOUGH, HEATHER C (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:C
Last Name:MCCULLOUGH
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 1:3434 HANCOCK BRIDGE PKWY
Mailing Address - Street 2:STE 301
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7099
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:333 TAMIAMI TRL S
Practice Address - Street 2:SUITE 101
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2402
Practice Address - Country:US
Practice Address - Phone:941-488-7716
Practice Address - Fax:941-488-0511
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59667207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12169OtherBCBS
FL055158900Medicaid
FL055158900Medicaid
FL12169OtherBCBS