Provider Demographics
NPI:1962671891
Name:MCCULLOCH, CARLOS (RT)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:MCCULLOCH
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4124 GUS THOMASSON RD
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2226
Mailing Address - Country:US
Mailing Address - Phone:214-221-4500
Mailing Address - Fax:214-221-5600
Practice Address - Street 1:4124 GUS THOMASSON RD
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2226
Practice Address - Country:US
Practice Address - Phone:214-221-4500
Practice Address - Fax:214-221-5600
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4598402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology