Provider Demographics
NPI:1356798102
Name:MCCULLOUGH, BRADLEY LEE JR (DO)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:LEE
Last Name:MCCULLOUGH
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 MDG
Mailing Address - Street 2:UNIT 3125 RAMSTEIN AB
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:86 MDG
Practice Address - Street 2:UNIT 3125 RAMSTEIN AB
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09094
Practice Address - Country:US
Practice Address - Phone:907-580-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXR7064207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program