Healthcare Provider Details

I. General information

NPI: 1881808947
Provider Name (Legal Business Name): TIMOTHY CASEY MCCULLOUGH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 05/04/2024
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10730 MEDLOCK BRIDGE RD STE 110
JOHNS CREEK GA
30097
US

IV. Provider business mailing address

1551 JANMAR RD
SNELLVILLE GA
30078-5606
US

V. Phone/Fax

Practice location:
  • Phone: 860-886-1956
  • Fax:
Mailing address:
  • Phone: 678-344-8900
  • Fax: 678-691-0506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number78199
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: