Provider Demographics
NPI:1932135704
Name:MCCULLOUGH, MICHAEL REID (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:REID
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 S GREAT SOUTHWEST PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1056
Mailing Address - Country:US
Mailing Address - Phone:972-988-1588
Mailing Address - Fax:972-602-0615
Practice Address - Street 1:643 S GREAT SOUTHWEST PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1056
Practice Address - Country:US
Practice Address - Phone:972-988-1588
Practice Address - Fax:972-602-0615
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9682207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033519201Medicaid
TX10028878OtherAMERIGROUP ID
TX1275832362Medicaid
TX4250747OtherAETNA ID
TXG74VOtherBLUE CROSS BLUE SHIELD ID
TX033519201OtherTPI
TX10028878OtherAMERIGROUP ID