Individual
MARTHA LYNN MCCOLLOUGH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1367 DOMINION PLAZA, TYLER, TX 75703-1013
(903) 534-6200
Mailing address
1367 DOMINION PLAZA, TYLER, TX 75703-1013
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
J5401
TX
207ND0900X
Dermatopathology Physician
J5401
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
044554601
—
TX
01
—
070012699
RAILROAD MEDICARE PTAN
TX
01
—
85Z813
BLUE CROSS AND BLUE SHIELD PATHOLOGY
TX
01
—
8A2686
BLUE CROSS AND BLUE SHIELD CLINIC
TX
Enumeration date
06/27/2006
Last updated
05/22/2008
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