Healthcare Provider Details

I. General information

NPI: 1245469519
Provider Name (Legal Business Name): RICKY JUSTIN MCCULLOUGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 POPLAR ST STE B
MACON GA
31201-3336
US

IV. Provider business mailing address

2675 WINKLER AVE STE 200
FORT MYERS FL
33901-9328
US

V. Phone/Fax

Practice location:
  • Phone: 478-746-0097
  • Fax: 478-742-4051
Mailing address:
  • Phone: 877-856-3774
  • Fax: 239-599-2612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number65151
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: