Provider Demographics
NPI:1902915671
Name:MCCOLLUM, CHARLES E (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:MCCOLLUM
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 1:1302 ENTERPRISE WAY
Mailing Address - Street 2:PO BOX 1754
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-997-6922
Mailing Address - Fax:
Practice Address - Street 1:1302 ENTERPRISE WAY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-997-6922
Practice Address - Fax:618-993-3561
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL047-006995152W00000X
IL046006995152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU28105Medicare UPIN
612720Medicare ID - Type Unspecified
U28105Medicare UPIN