Provider Demographics
NPI:1407844558
Name:MCCOLLUM, ALFONZA JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFONZA
Middle Name:
Last Name:MCCOLLUM
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 9671
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9671
Mailing Address - Country:US
Mailing Address - Phone:386-676-7130
Mailing Address - Fax:386-676-7125
Practice Address - Street 1:461 SOUTH NOVA ROAD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:33174-6138
Practice Address - Country:US
Practice Address - Phone:386-671-4337
Practice Address - Fax:386-671-7242
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2015-11-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME83401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1407844558OtherTRICARE
FL267116600Medicaid
FLP00444511OtherRAILROAD MEDICARE NUMBER
FL57851OtherBCBS
FLP00444511OtherRAILROAD MEDICARE NUMBER