Healthcare Provider Details

I. General information

NPI: 1366535890
Provider Name (Legal Business Name): ANDREA MCCULLOUGH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RIVER DR
FORT BRAGG CA
95437-5403
US

IV. Provider business mailing address

2107 LIVINGSTON ST SUITE A
OAKLAND CA
94606-5218
US

V. Phone/Fax

Practice location:
  • Phone: 707-961-4655
  • Fax:
Mailing address:
  • Phone: 510-436-9000
  • Fax: 510-436-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberA61951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: