Provider Demographics
NPI:1942871645
Name:MCCULLOUGH, ALEXIS MAKIKO (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:MAKIKO
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:2556 CHICAGO ST UNIT 28
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4161
Mailing Address - Country:US
Mailing Address - Phone:310-480-0216
Mailing Address - Fax:
Practice Address - Street 1:4353 LA JOLLA VILLAGE DR STE H-20
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1242
Practice Address - Country:US
Practice Address - Phone:858-622-2165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist