Healthcare Provider Details

I. General information

NPI: 1255448122
Provider Name (Legal Business Name): MICHAEL MCCULLOUGH I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 05/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 FRESNO ST
FRESNO CA
93721-1324
US

IV. Provider business mailing address

1824 OAK CREEK DR # 308
PALO ALTO CA
94304-2158
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA63113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: