Healthcare Provider Details

I. General information

NPI: 1841345725
Provider Name (Legal Business Name): TIMOTHY JOHN MCCULLOUGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BRIDGE ST STE 202
DANVILLE VA
24541-1222
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone: 434-792-5964
  • Fax:
Mailing address:
  • Phone: 434-792-5964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number149086
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101260704
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: