Healthcare Provider Details

I. General information

NPI: 1083977466
Provider Name (Legal Business Name): MICHAEL-FLYNN LAGOZZINO CULLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

9040 JACKSON AVE MADIGAN ARMY MEDICAL CENTER
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2252
  • Fax:
Mailing address:
  • Phone: 253-477-2004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberR5713
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: