Provider Demographics
NPI:1336256973
Name:CULMER, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CULMER
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 1:1294 W 6TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2987
Mailing Address - Country:US
Mailing Address - Phone:321-054-8911
Mailing Address - Fax:310-548-1310
Practice Address - Street 1:1294 W 6TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2987
Practice Address - Country:US
Practice Address - Phone:321-054-8911
Practice Address - Fax:310-548-1310
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67275208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A672750Medicaid
WA67275BMedicare ID - Type UnspecifiedMEDICARE PART B PPIN
CA00A672750Medicaid