Healthcare Provider Details

I. General information

NPI: 1043500721
Provider Name (Legal Business Name): ROBERT JONATHAN MCCULLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 06/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE RD
TRIPLER ARMY MEDICAL CENTER HI
96859-5001
US

IV. Provider business mailing address

1 JARRETT WHITE RD
TRIPLER ARMY MEDICAL CENTER HI
96859-5001
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-6345
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17804
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number17804
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: