Provider Demographics
NPI:1538164728
Name:MCCULLAH, HEIDI MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:MARIE
Last Name:MCCULLAH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:10147 MASTERS RD
Mailing Address - Street 2:
Mailing Address - City:WALES
Mailing Address - State:MI
Mailing Address - Zip Code:48027-2720
Mailing Address - Country:US
Mailing Address - Phone:810-392-2820
Mailing Address - Fax:810-385-5212
Practice Address - Street 1:4845 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3407
Practice Address - Country:US
Practice Address - Phone:810-358-4114
Practice Address - Fax:810-385-5212
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2008-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004241152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P44510Medicare PIN
V01273Medicare UPIN