Provider Demographics
NPI:1861840282
Name:MCCULLOUGH, MEGAN (MD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
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 1:950 CAMPBELL AVE DEPT OF
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-2770
Mailing Address - Country:US
Mailing Address - Phone:203-932-5711
Mailing Address - Fax:
Practice Address - Street 1:789 HOWARD AVENUE
Practice Address - Street 2:YNHH DEPARTMENT OF INTERNAL MEDICINE
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06520-8025
Practice Address - Country:US
Practice Address - Phone:203-688-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT62491207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program