Provider Demographics
NPI:1942216478
Name:MCCULLOUGH, DEBORAH L (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:L
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:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:
Practice Address - Street 1:6091 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2619
Practice Address - Country:US
Practice Address - Phone:219-763-8113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026315A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000084532OtherANTHEM
IN100147650AMedicaid
IN100147650AMedicaid
IN495580Medicare ID - Type Unspecified