Healthcare Provider Details

I. General information

NPI: 1114064029
Provider Name (Legal Business Name): DR. ALEXANDER T MCCULLOCH JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 CORPORATE DR
COLORADO SPRINGS CO
80919-1941
US

IV. Provider business mailing address

AESTHETIC SURGERY CENTER OF COLORADO 5901 CORPORATE DRIVE
COLORADO SPRINGS CO
80919
US

V. Phone/Fax

Practice location:
  • Phone: 719-597-1200
  • Fax: 719-597-2333
Mailing address:
  • Phone: 719-597-1200
  • Fax: 719-597-2333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number24965
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: