Provider Demographics
NPI:1992809057
Name:MCCULLOUGH, RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-1909
Mailing Address - Country:US
Mailing Address - Phone:740-623-0110
Mailing Address - Fax:740-623-0318
Practice Address - Street 1:618 S 2ND ST
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-1909
Practice Address - Country:US
Practice Address - Phone:740-623-0110
Practice Address - Fax:740-623-0318
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2990152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0251981Medicaid
OHT46597Medicare UPIN
OH1639314537Medicare NSC
OH0289500001Medicare PIN
OH0251981Medicaid