Healthcare Provider Details

I. General information

NPI: 1548898489
Provider Name (Legal Business Name): JOCELYN JERUSHA MCCULLOUGH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 UNION BLVD
WEST ISLIP NY
11795-3105
US

IV. Provider business mailing address

540 UNION BLVD
WEST ISLIP NY
11795-3105
US

V. Phone/Fax

Practice location:
  • Phone: 631-669-2555
  • Fax: 631-669-5787
Mailing address:
  • Phone: 631-669-2555
  • Fax: 631-669-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number343448
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: