Provider Demographics
NPI:1699823005
Name:MCCOLLOM, BRIAN D (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:D
Last Name:MCCOLLOM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CHOTEAU
Mailing Address - State:MT
Mailing Address - Zip Code:59422-9123
Mailing Address - Country:US
Mailing Address - Phone:406-466-2802
Mailing Address - Fax:406-466-2732
Practice Address - Street 1:913 4TH ST NW
Practice Address - Street 2:
Practice Address - City:CHOTEAU
Practice Address - State:MT
Practice Address - Zip Code:59422-9123
Practice Address - Country:US
Practice Address - Phone:406-466-2802
Practice Address - Fax:406-466-2732
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT746152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0482817Medicaid
MT0482817Medicaid
MTU96.95Medicare UPIN
000085176Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #
MT4915810001Medicare NSC