Basic Information
| Provider Information | |||||||||
| NPI: | 1790788966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | SOPHIA | ||||||||
| MiddleName: | GRECOS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3355 GLENDALE AVE. | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436144361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5679522100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1089 PRAY BLVD | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435668712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5679522100 | ||||||||
| FaxNumber: | 5679522010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35083028 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0192437 | 05 | OH | MEDICAID | 029078500 | 05 | MD | MEDICAID |