Provider Demographics
NPI:1790154813
Name:MCCULLOUGH, FRANKLIN PAUL (IDC)
Entity Type:Individual
Prefix:
First Name:FRANKLIN
Middle Name:PAUL
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BON HOMME ST BLDG 2480
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32228
Mailing Address - Country:US
Mailing Address - Phone:484-678-8463
Mailing Address - Fax:
Practice Address - Street 1:BON HOMME ST BLDG 2480
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32228
Practice Address - Country:US
Practice Address - Phone:484-678-8463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman