1841323300 NPI number — DR. JAROD LANCE MCCULLOUGH O.D.

Table of content: DR. JAROD LANCE MCCULLOUGH O.D. (NPI 1841323300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841323300 NPI number — DR. JAROD LANCE MCCULLOUGH O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCULLOUGH
Provider First Name:
JAROD
Provider Middle Name:
LANCE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841323300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 WALNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FESTUS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63028-1850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-937-3130
Provider Business Mailing Address Fax Number:
636-937-7202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FESTUS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63028-1850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-937-3130
Provider Business Practice Location Address Fax Number:
636-937-7202
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2002014341 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 892837 . This is a "MERCY CARE PLUS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 36609 . This is a "BOILERMAKERS NATIONAL H&W" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 1684191 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 189230 . This is a "ANTHEM BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 320123262 . This is a "CONSTRUCTION LABORERS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 44844 . This is a "DAVIS VISION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 49877 . This is a "HEALTHCARE USA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 7942654 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 061 1012754 . This is a "EYEMED VISION CARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 197614 . This is a "GREAT-WEST HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 262102 . This is a "NVA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 319118907 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 509638 . This is a "EPOCH" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 648 . This is a "SVS VISION" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 16528 . This is a "SPECTERA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 32-0123262 . This is a "VBA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 320123262 . This is a "VISION SERVICE PLAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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