Provider Demographics
NPI:1770670655
Name:KATHLEEN A CULLEN MD PA
Entity Type:Organization
Organization Name:KATHLEEN A CULLEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-392-8600
Mailing Address - Street 1:10575 68TH AVE
Mailing Address - Street 2:SUITE A1
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-6035
Mailing Address - Country:US
Mailing Address - Phone:727-392-8600
Mailing Address - Fax:727-392-8686
Practice Address - Street 1:10575 68TH AVE
Practice Address - Street 2:SUITE A1
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-6035
Practice Address - Country:US
Practice Address - Phone:727-392-8600
Practice Address - Fax:727-392-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70549207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD795Medicare PIN
FLG26783Medicare UPIN