Provider Demographics
NPI:1720402977
Name:MCCOLL, MILTON BIRD (MD)
Entity Type:Individual
Prefix:
First Name:MILTON
Middle Name:BIRD
Last Name:MCCOLL
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 1:4751 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-3707
Mailing Address - Country:US
Mailing Address - Phone:602-277-7526
Mailing Address - Fax:
Practice Address - Street 1:455 OCONNOR DR STE 200
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1632
Practice Address - Country:US
Practice Address - Phone:408-283-7676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-08
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ62712207Q00000X
CAGFE68043208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG68043OtherCA PHYSICIAN AND SURGEON LICENSE
AZ62712OtherFAMILY MEDICINE