Provider Demographics
NPI:1164491924
Name:COLLINS, LARRY L (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:L
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 1:1151 N STATE ST
Mailing Address - Street 2:SUITE 408
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2407
Mailing Address - Country:US
Mailing Address - Phone:601-957-1015
Mailing Address - Fax:601-956-9721
Practice Address - Street 1:6250 OLD CANTON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2946
Practice Address - Country:US
Practice Address - Phone:601-957-1015
Practice Address - Fax:601-956-9721
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09096207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS753068151003OtherTRICARE
MS00011793Medicaid
MSP00072975OtherRR MEDICARE
MS4405163OtherAETNA
MS$$$$$$$$$BOtherBCBS
MS80003806Medicare ID - Type Unspecified
MS00011793Medicaid