Provider Demographics
NPI:1881778215
Name:MCCULLOCH, ALLEN WILSON (MD)
Entity type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:WILSON
Last Name:MCCULLOCH
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1529
Mailing Address - Street 2:2300 E 30TH BLDG B SUITE 106
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-327-9111
Mailing Address - Fax:505-327-2730
Practice Address - Street 1:2300 E 30TH
Practice Address - Street 2:BLDG B SUITE 106
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-327-9111
Practice Address - Fax:505-327-2730
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2013-06-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM87 115208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11338Medicaid
C97959Medicare UPIN
NM11338Medicaid