Provider Demographics
NPI:1922452705
Name:MCCULLOUGH, MARY GRAHAM (DOM)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:GRAHAM
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 SAN PEDRO DR NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3326
Mailing Address - Country:US
Mailing Address - Phone:505-433-7472
Mailing Address - Fax:
Practice Address - Street 1:2716 SAN PEDRO DR NE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3326
Practice Address - Country:US
Practice Address - Phone:505-433-7472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1178171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist