Provider Demographics
NPI:1073599791
Name:COLLINS, STEPHANIE W (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:W
Last Name:COLLINS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 OCEAN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2855
Mailing Address - Country:US
Mailing Address - Phone:207-747-4455
Mailing Address - Fax:888-907-5762
Practice Address - Street 1:96 OCEAN ST STE 4
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2855
Practice Address - Country:US
Practice Address - Phone:207-747-4455
Practice Address - Fax:888-907-5762
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO1663204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME254890099Medicaid
MEH45037Medicare UPIN
MEMM8997Medicare ID - Type Unspecified