Provider Demographics
NPI:1972708881
Name:MCCULLOUGH, DEANNA C (MD)
Entity type:Individual
Prefix:DR
First Name:DEANNA
Middle Name:C
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653-1 W 8TH ST
Mailing Address - Street 2:3RD FLOOR, LRC
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6511
Mailing Address - Country:US
Mailing Address - Phone:904-244-3112
Mailing Address - Fax:
Practice Address - Street 1:653-1 W 8TH ST
Practice Address - Street 2:3RD FLOOR, LRC
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-3112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2016-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
FLME 125274207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No171000000XOther Service ProvidersMilitary Health Care Provider