Provider Demographics
NPI:1447257308
Name:CULLEN, EDWARD CLARK (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:CLARK
Last Name:CULLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:E.
Other - Middle Name:CLARK
Other - Last Name:CULLEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1910 E. BARNETT RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8672
Mailing Address - Country:US
Mailing Address - Phone:541-727-8972
Mailing Address - Fax:833-638-0201
Practice Address - Street 1:1910 E. BARNETT RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8672
Practice Address - Country:US
Practice Address - Phone:541-727-8972
Practice Address - Fax:833-638-0201
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR008347Medicaid
ORA51985Medicare UPIN
OR008347Medicaid