Provider Demographics
NPI:1083036073
Name:MCCOLLUM, JOHN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:MCCOLLUM
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 1:4259 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1421
Mailing Address - Country:US
Mailing Address - Phone:503-358-3506
Mailing Address - Fax:
Practice Address - Street 1:4259 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1421
Practice Address - Country:US
Practice Address - Phone:503-358-3506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7727174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist