Provider Demographics
NPI:1235240425
Name:COLLINS, SHELLY L (OD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:L
Last Name:COLLINS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 W WILLIAM CANNON
Mailing Address - Street 2:B210
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749
Mailing Address - Country:US
Mailing Address - Phone:512-328-0015
Mailing Address - Fax:512-328-7638
Practice Address - Street 1:4301 W WILLIAM CANNON DR
Practice Address - Street 2:SUITE B210
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1473
Practice Address - Country:US
Practice Address - Phone:512-328-0015
Practice Address - Fax:512-328-7638
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4786TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U44679Medicare UPIN
TX8A0735Medicare ID - Type Unspecified