Provider Demographics
NPI:1972666212
Name:MCCULLOUGH, JAMES FRANCIS (RDO)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:FRANCIS
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550
Mailing Address - Country:US
Mailing Address - Phone:508-765-9607
Mailing Address - Fax:508-765-9607
Practice Address - Street 1:343 MAIN STREET
Practice Address - Street 2:SOUTHBRIDGE SPECTACLE SHOP
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550
Practice Address - Country:US
Practice Address - Phone:508-765-9607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA1543156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1522191Medicaid
0868540001Medicare ID - Type Unspecified