Provider Demographics
NPI:1528003654
Name:MCCULLOUGH, PAUL CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:CHARLES
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4209 28TH ST # CN-48
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-4130
Mailing Address - Country:US
Mailing Address - Phone:347-396-6299
Mailing Address - Fax:347-396-6367
Practice Address - Street 1:295 FLATBUSH AVENUE EXT FL 4
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3001
Practice Address - Country:US
Practice Address - Phone:718-249-1468
Practice Address - Fax:718-249-1488
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140640-01207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B14332Medicare UPIN
010567Medicare ID - Type UnspecifiedGHI
410781Medicare ID - Type UnspecifiedEMPIRE
010560Medicare ID - Type UnspecifiedGHI