Provider Demographics
NPI:1902809783
Name:MCCULLERS, JONATHAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:A
Last Name:MCCULLERS
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 1:262 DANNY THOMAS PL
Mailing Address - Street 2:MS 515
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3678
Mailing Address - Country:US
Mailing Address - Phone:901-595-3006
Mailing Address - Fax:901-595-3842
Practice Address - Street 1:262 DANNY THOMAS PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3678
Practice Address - Country:US
Practice Address - Phone:901-595-3006
Practice Address - Fax:901-595-3842
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN282172080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0535716Medicaid
SCQ28217Medicaid
LA1562645Medicaid
TX177291601Medicaid
TN3898345Medicaid
MS00121412Medicaid
MO205028509Medicaid
VA010195918Medicaid
OK100030710AMedicaid
AR137756001Medicaid
AL009914410Medicaid
ME422400000Medicaid
WY1145860 00Medicaid
SCQ28217Medicaid