Provider Demographics
NPI:1487757548
Name:MCGULLION, DIRK D
Entity type:Individual
Prefix:
First Name:DIRK
Middle Name:D
Last Name:MCGULLION
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2120
Mailing Address - Street 2:
Mailing Address - City:RAINSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35986-2120
Mailing Address - Country:US
Mailing Address - Phone:256-638-2020
Mailing Address - Fax:256-638-7832
Practice Address - Street 1:463 MAIN ST W
Practice Address - Street 2:
Practice Address - City:RAINSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35986
Practice Address - Country:US
Practice Address - Phone:256-638-2020
Practice Address - Fax:256-638-7832
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS818TA058152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51058647OtherBCBS
AL000058647Medicaid
AL000058647Medicaid
ALU56624Medicare UPIN