Provider Demographics
NPI:1003830399
Name:COLLINS, JOHN O (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:O
Last Name:COLLINS
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 1:2510 E DUPONT RD
Mailing Address - Street 2:STE 201
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1601
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:4420 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607
Practice Address - Country:US
Practice Address - Phone:919-784-7093
Practice Address - Fax:919-784-7395
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01070620A2084N0400X
OH35.1278352084N0400X
NC2009-013572084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201050780Medicaid
OH0060443Medicaid
OHH253180Medicare PIN
IN201050780Medicaid
IN221480002Medicare PIN
IN523080002Medicare PIN
IN941050015Medicare PIN
INM400063215Medicare PIN