Provider Demographics
NPI:1164483087
Name:COLLINS, DIANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5435 S BLACKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5406
Mailing Address - Country:US
Mailing Address - Phone:312-320-0777
Mailing Address - Fax:
Practice Address - Street 1:5435 S BLACKSTONE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5406
Practice Address - Country:US
Practice Address - Phone:312-320-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084725207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-08725OtherILLINOIS STATE LICENSE
IL036-08725OtherILLINOIS STATE LICENSE