Provider Demographics
NPI:1225019375
Name:COLLIER, MARY DIANE (DPM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DIANE
Last Name:COLLIER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 LUDS WAY
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-6350
Mailing Address - Country:US
Mailing Address - Phone:334-678-7036
Mailing Address - Fax:334-702-4208
Practice Address - Street 1:204 LUDS WAY
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-6350
Practice Address - Country:US
Practice Address - Phone:334-678-7036
Practice Address - Fax:334-702-4208
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL190213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL77827OtherBCBS
AL1281950001OtherDMERC, PALMETTO GOVERNMEN
ALU70118Medicare UPIN
AL0000077827Medicare PIN