Provider Demographics
NPI:1215919956
Name:CULLEN, MARK RICHARD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:CULLEN
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 1:251 CAMPUS DR
Mailing Address - Street 2:MSOB X338
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-5101
Mailing Address - Country:US
Mailing Address - Phone:650-721-6209
Mailing Address - Fax:
Practice Address - Street 1:251 CAMPUS DR
Practice Address - Street 2:MSOB X338
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-5101
Practice Address - Country:US
Practice Address - Phone:650-721-6209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0200602083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001200609Medicaid
CT110001683Medicare ID - Type Unspecified
CT001200609Medicaid