Provider Demographics
NPI:1912318049
Name:MCCULLAR, BRENNAN (MD)
Entity Type:Individual
Prefix:
First Name:BRENNAN
Middle Name:
Last Name:MCCULLAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6019 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2113
Practice Address - Country:US
Practice Address - Phone:901-226-3610
Practice Address - Fax:901-226-3612
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25587207R00000X
ARE-13241207R00000X
TN55466207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty