Provider Demographics
NPI:1760456305
Name:CULLEN, STEPHEN L (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:CULLEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 STATE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-8505
Mailing Address - Country:US
Mailing Address - Phone:812-254-4650
Mailing Address - Fax:812-254-4081
Practice Address - Street 1:2005 STATE ST
Practice Address - Street 2:SUITE A
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-8505
Practice Address - Country:US
Practice Address - Phone:812-254-4650
Practice Address - Fax:812-254-4081
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000680207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000915642OtherANTHEM
IN100122300Medicaid
IN258190057Medicare PIN
INC24764Medicare UPIN
IN941140041Medicare PIN