Provider Demographics
NPI:1194787408
Name:CULLISON, JAMES WESLEY (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:WESLEY
Last Name:CULLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CLINIC AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4401
Mailing Address - Country:US
Mailing Address - Phone:770-834-6988
Mailing Address - Fax:770-834-1090
Practice Address - Street 1:150 CLINIC AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4401
Practice Address - Country:US
Practice Address - Phone:770-834-6988
Practice Address - Fax:770-834-1090
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045057208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAREF906223411OtherMEDICAID REFERENCE NUMBER
GA875799007BMedicaid