Provider Demographics
NPI:1134101389
Name:MACCALLUM, JOHN P (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:MACCALLUM
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 1:404 TATE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-9746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:618 N HOWE ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3426
Practice Address - Country:US
Practice Address - Phone:910-454-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-022752084P0800X
WV105522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0116818000Medicaid
WV4242714OtherAETNA
WVB441OtherGROUP MEDICARE
WV001722474OtherBLUE CROSS BLUE SHIELD
WVB441OtherGROUP MEDICARE
WV4242714OtherAETNA
WVWV4890B441Medicare PIN