Provider Demographics
NPI:1346612702
Name:COLLINS, MICHAEL BLAKE (SFIDC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BLAKE
Last Name:COLLINS
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10255 LAFFEY CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2918
Mailing Address - Country:US
Mailing Address - Phone:757-647-2668
Mailing Address - Fax:
Practice Address - Street 1:10255 LAFFEY CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-2918
Practice Address - Country:US
Practice Address - Phone:757-647-2668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman