Provider Demographics
NPI:1548264385
Name:MCCOLLOM, BRAD E (DO)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:E
Last Name:MCCOLLOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8005 BAY ST STE 5
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3244
Mailing Address - Country:US
Mailing Address - Phone:772-581-8075
Mailing Address - Fax:772-581-8031
Practice Address - Street 1:8005 BAY ST STE 5
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3244
Practice Address - Country:US
Practice Address - Phone:772-581-8075
Practice Address - Fax:772-581-8031
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS9270207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL48160OtherBCBS FL
FLH88669Medicare UPIN
FL48160YMedicare PIN