Healthcare Provider Details

I. General information

NPI: 1942230610
Provider Name (Legal Business Name): BRIAN CULLIGAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E. NIZHONI BLVD BOX 1337
GALLUP NM
87301-1337
US

IV. Provider business mailing address

516 E. NIZHONI BLVD BOX 1337
GALLUP NM
87301-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1747
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1930
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: