Healthcare Provider Details

I. General information

NPI: 1134101389
Provider Name (Legal Business Name): JOHN P MACCALLUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 N HOWE ST
SOUTHPORT NC
28461-3426
US

IV. Provider business mailing address

404 TATE LAKE DR
SOUTHPORT NC
28461-9746
US

V. Phone/Fax

Practice location:
  • Phone: 910-454-0404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2015-02275
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number10552
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: