Provider Demographics
NPI:1902909815
Name:MCCALLUM, RICHARD W (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:MCCALLUM
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 1:5130 GATEWAY BLVD E # 51015
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-1608
Mailing Address - Country:US
Mailing Address - Phone:915-215-4480
Mailing Address - Fax:915-215-5386
Practice Address - Street 1:4801 ALBERTA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2707
Practice Address - Country:US
Practice Address - Phone:915-545-6618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-26660207RG0100X
TXQ2019207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100295910AMedicaid
KS626510OtherFIRSTGUARD
MO23793011OtherBCBS KC
MO208658500Medicaid
KS0119813AMedicare ID - Type Unspecified
KS110143139Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MO208658500Medicaid