Healthcare Provider Details

I. General information

NPI: 1043743479
Provider Name (Legal Business Name): KYLE ALAN MCCULLOUGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 11/02/2025
Certification Date: 11/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-1921
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-1921
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-1411
  • Fax:
Mailing address:
  • Phone: 860-679-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberU5754
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number81585
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberU5754
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: