Healthcare Provider Details

I. General information

NPI: 1104112747
Provider Name (Legal Business Name): JEREMY DAVID MCCULLOUGH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 N SARATOGA ST
OAK HARBOR WA
98278-0001
US

IV. Provider business mailing address

10318 STRATHMORE HALL ST APT. 408
ROCKVILLE MD
20852-6635
US

V. Phone/Fax

Practice location:
  • Phone: 360-257-9972
  • Fax:
Mailing address:
  • Phone: 786-512-1488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number010220312
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: