Provider Demographics
NPI:1912023714
Name:MCCULLEY, MELISSA J (OD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:J
Last Name:MCCULLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2553 KIRSTEN LN S # 202
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4901
Mailing Address - Country:US
Mailing Address - Phone:701-373-2020
Mailing Address - Fax:701-373-0021
Practice Address - Street 1:2553 KIRSTEN LN S # 202
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4901
Practice Address - Country:US
Practice Address - Phone:701-373-2020
Practice Address - Fax:701-373-0021
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND597152W00000X
MN2824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN88G84MCOtherBLUE SHIELD
ND026373OtherBLUE SHIELD
MN88G84MCOtherBLUE SHIELD
ND711750Medicare ID - Type Unspecified