Healthcare Provider Details

I. General information

NPI: 1780212316
Provider Name (Legal Business Name): IAN LAMBOURNE MCCULLOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 FRANKLIN AVE
GARDEN CITY NY
11530-2913
US

IV. Provider business mailing address

999 FRANKLIN AVE
GARDEN CITY NY
11530-2913
US

V. Phone/Fax

Practice location:
  • Phone: 516-742-3404
  • Fax:
Mailing address:
  • Phone: 516-742-3404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number343659
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: