Provider Demographics
NPI:1740433663
Name:MCCULLOUGH, DAVID R (RN)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80810
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87198-0810
Mailing Address - Country:US
Mailing Address - Phone:505-383-1143
Mailing Address - Fax:505-841-8977
Practice Address - Street 1:5901 ZUNI RD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-3073
Practice Address - Country:US
Practice Address - Phone:505-383-1143
Practice Address - Fax:585-841-8977
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR30246163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR30246OtherSPECIAL HOSPITAL