Provider Demographics
NPI:1841323300
Name:MCCULLOUGH, JAROD LANCE (OD)
Entity type:Individual
Prefix:DR
First Name:JAROD
Middle Name:LANCE
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:202 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1850
Mailing Address - Country:US
Mailing Address - Phone:636-937-3130
Mailing Address - Fax:636-937-7202
Practice Address - Street 1:202 WALNUT ST
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1850
Practice Address - Country:US
Practice Address - Phone:636-937-3130
Practice Address - Fax:636-937-7202
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002014341152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
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PA1684191OtherHIGHMARK BLUE SHIELD
MO189230OtherANTHEM BCBS
MO320123262OtherCONSTRUCTION LABORERS
NY44844OtherDAVIS VISION
MO49877OtherHEALTHCARE USA
KY7942654OtherAETNA
MO061 1012754OtherEYEMED VISION CARE
MO197614OtherGREAT-WEST HEALTHCARE
NJ262102OtherNVA
MO319118907Medicaid
MO509638OtherEPOCH
MI648OtherSVS VISION
MA16528OtherSPECTERA
PA32-0123262OtherVBA
CA320123262OtherVISION SERVICE PLAN
MO320123262OtherCONSTRUCTION LABORERS
MO49877OtherHEALTHCARE USA