Healthcare Provider Details

I. General information

NPI: 1790788966
Provider Name (Legal Business Name): SOPHIA GRECOS MCCULLOUGH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1089 PRAY BLVD
WATERVILLE OH
43566-8712
US

IV. Provider business mailing address

3000 ARLINGTON AVE STOP 1108
TOLEDO OH
43614-2595
US

V. Phone/Fax

Practice location:
  • Phone: 567-952-2100
  • Fax: 567-952-2010
Mailing address:
  • Phone: 419-383-5322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35083028
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: