Healthcare Provider Details

I. General information

NPI: 1356409411
Provider Name (Legal Business Name): JEFFREY A. CULLEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6973 LINDA VISTA ROAD
SAN DIEGO CA
92111-6342
US

IV. Provider business mailing address

6973 LINDA VISTA ROAD
SAN DIEGO CA
92111-6342
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-9676
  • Fax: 858-279-0377
Mailing address:
  • Phone: 858-279-9676
  • Fax: 858-279-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number036094493
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036094493
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036094493
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC54416
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: