Provider Demographics
NPI:1295099372
Name:MCCULLOCH, CANDI (MD)
Entity type:Individual
Prefix:DR
First Name:CANDI
Middle Name:
Last Name:MCCULLOCH
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 1:38 SHAWANDASSEE ROAD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06358-1419
Mailing Address - Country:US
Mailing Address - Phone:860-961-6229
Mailing Address - Fax:
Practice Address - Street 1:38 SHAWANDASSEE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1419
Practice Address - Country:US
Practice Address - Phone:860-961-6229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT050188207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine