Healthcare Provider Details

I. General information

NPI: 1356798102
Provider Name (Legal Business Name): BRADLEY LEE MCCULLOUGH JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 07/08/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 MDG UNIT 3125 RAMSTEIN AB
APO AE
09094
US

IV. Provider business mailing address

86 MDG UNIT 3125 RAMSTEIN AB
APO AE
09094
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-8121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR7064
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: