Provider Demographics
NPI:1396951620
Name:CULNAN, DEREK (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:CULNAN
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:PO BOX 2204
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-2204
Mailing Address - Country:US
Mailing Address - Phone:833-672-8767
Mailing Address - Fax:
Practice Address - Street 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2064
Practice Address - Country:US
Practice Address - Phone:833-672-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24649208600000X, 2086S0102X, 208200000X
IDM-14601208600000X, 2086S0102X
GA77246208600000X
CODR.00576552086S0102X
FLME1323392086S0102X
IN01073854A2086S0102X
NC2020-026642086S0102X
NV193002086S0102X
PAMD4324542086S0102X
TNMD00000618382086S0102X
TXQ47392086S0102X
VA01012693272086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery