Provider Demographics
NPI:1043743479
Name:MCCULLOUGH, KYLE ALAN (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:ALAN
Last Name:MCCULLOUGH
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 1:2710 SWISS AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-5900
Mailing Address - Country:US
Mailing Address - Phone:214-821-1599
Mailing Address - Fax:
Practice Address - Street 1:2710 SWISS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-5900
Practice Address - Country:US
Practice Address - Phone:214-821-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU57542086S0102X, 208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program