Healthcare Provider Details

I. General information

NPI: 1811252778
Provider Name (Legal Business Name): BENJAMIN JOSEPH MCCOLLUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 AVENUE E
HONDO TX
78861-3534
US

IV. Provider business mailing address

PO BOX 335
HONDO TX
78861-0335
US

V. Phone/Fax

Practice location:
  • Phone: 830-426-7444
  • Fax:
Mailing address:
  • Phone: 505-879-7929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71446
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberU9600
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: