Provider Demographics
NPI:1790788966
Name:MCCULLOUGH, SOPHIA GRECOS (MD)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:GRECOS
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 1:3355 GLENDALE AVE.
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-4361
Mailing Address - Country:US
Mailing Address - Phone:567-952-2100
Mailing Address - Fax:
Practice Address - Street 1:1089 PRAY BLVD
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-8712
Practice Address - Country:US
Practice Address - Phone:567-952-2100
Practice Address - Fax:567-952-2010
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083028208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0192437Medicaid
MD029078500Medicaid
OHH526670Medicare PIN