Provider Demographics
NPI:1982692661
Name:MCCULLOUGH, MICHAEL PATRICK (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BRYANT WILLIAMS DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1121
Mailing Address - Country:US
Mailing Address - Phone:541-884-7746
Mailing Address - Fax:541-884-0848
Practice Address - Street 1:2200 BRYANT WILLIAMS DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1121
Practice Address - Country:US
Practice Address - Phone:541-884-7746
Practice Address - Fax:541-884-0848
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00178213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01237834OtherRAIL ROAD MEDICARE
ORP01237834OtherRAIL ROAD MEDICARE
ORP01237834OtherRAIL ROAD MEDICARE
ORT67895Medicare UPIN
OR7233750001Medicare NSC