Provider Demographics
NPI:1184606535
Name:MCCOLLOUGH, JOHN S (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:MCCOLLOUGH
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 1:4406 N LAURENT
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-2791
Mailing Address - Country:US
Mailing Address - Phone:361-578-0107
Mailing Address - Fax:361-578-1320
Practice Address - Street 1:4406 N LAURENT
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-2791
Practice Address - Country:US
Practice Address - Phone:361-578-0107
Practice Address - Fax:361-578-1320
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2620T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127231206Medicaid
TX8724B7Medicare ID - Type Unspecified
T14690Medicare UPIN