Provider Demographics
NPI:1215231675
Name:COLLINS, BRENT DOUGLAS (OD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:DOUGLAS
Last Name:COLLINS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 CHILD STREET OPTOMETRY CLINIC
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-0001
Mailing Address - Country:US
Mailing Address - Phone:904-542-7300
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD STREET OPTOMETRY CLINIC
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-1098
Practice Address - Country:US
Practice Address - Phone:904-542-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-28
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14007 TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist