Provider Demographics
NPI:1811252778
Name:MCCOLLUM, BENJAMIN JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOSEPH
Last Name:MCCOLLUM
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:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:HONDO
Mailing Address - State:TX
Mailing Address - Zip Code:78861-0335
Mailing Address - Country:US
Mailing Address - Phone:505-879-7929
Mailing Address - Fax:
Practice Address - Street 1:3100 AVENUE E
Practice Address - Street 2:
Practice Address - City:HONDO
Practice Address - State:TX
Practice Address - Zip Code:78861-3534
Practice Address - Country:US
Practice Address - Phone:830-426-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA71446207Q00000X
TXU9600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty