Provider Demographics
NPI:1912068289
Name:MCCULLOUGH, LESLIE LEE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:LEE
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 N CENTRAL AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5873
Mailing Address - Country:US
Mailing Address - Phone:541-734-9030
Mailing Address - Fax:541-734-9885
Practice Address - Street 1:1600 DELTA WATERS RD
Practice Address - Street 2:SUITE 107
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9114
Practice Address - Country:US
Practice Address - Phone:541-858-2515
Practice Address - Fax:541-858-2514
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR113738Medicaid
MD11227OtherMEDICAL LICENSE
MD11227OtherMEDICAL LICENSE
OR113738Medicaid
R153263Medicare PIN