Healthcare Provider Details

I. General information

NPI: 1497722219
Provider Name (Legal Business Name): MARK C CULLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 CORPORATE DR, 2ND FL
PORTSMOUTH NH
03801
US

IV. Provider business mailing address

7 MARSH BROOK DR STE 205
SOMERSWORTH NH
03878-6523
US

V. Phone/Fax

Practice location:
  • Phone: 603-810-8078
  • Fax:
Mailing address:
  • Phone: 603-742-2007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number19638
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: