Provider Demographics
NPI:1023129905
Name:MCCALL, CALVIN ODELL JR (MD)
Entity type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:ODELL
Last Name:MCCALL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CALVIN
Other - Middle Name:O
Other - Last Name:MCCALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1201 BROAD ROCK BLVD
Mailing Address - Street 2:DERMATOLOGY/111L
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23249-0001
Mailing Address - Country:US
Mailing Address - Phone:804-675-5000
Mailing Address - Fax:804-675-5670
Practice Address - Street 1:1201 BROAD ROCK BLVD
Practice Address - Street 2:DERMATOLOGY/111L
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-5000
Practice Address - Fax:804-675-5670
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042351207N00000X
VA0101037654207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00713358BMedicaid
07BBCQXMedicare ID - Type Unspecified
B10252Medicare UPIN