Provider Demographics
NPI:1902885015
Name:CULLOM, SUMNER R (MD)
Entity Type:Individual
Prefix:
First Name:SUMNER
Middle Name:R
Last Name:CULLOM
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 1:260 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LEPANTO
Mailing Address - State:AR
Mailing Address - Zip Code:72354-0000
Mailing Address - Country:US
Mailing Address - Phone:870-475-3180
Mailing Address - Fax:870-475-3185
Practice Address - Street 1:260 W BROAD ST
Practice Address - Street 2:
Practice Address - City:LEPANTO
Practice Address - State:AR
Practice Address - Zip Code:72354-0723
Practice Address - Country:US
Practice Address - Phone:870-475-3180
Practice Address - Fax:870-475-3185
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARARC4583208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103504001Medicaid
043860OtherTRAILBLAZERS
C68113Medicare UPIN
51246Medicare ID - Type Unspecified