Provider Demographics
NPI:1477560530
Name:COLLIS, DEAN STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:STANLEY
Last Name:COLLIS
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 1:315 E BROADWAY
Mailing Address - Street 2:STE 250
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3700
Mailing Address - Country:US
Mailing Address - Phone:502-589-4765
Mailing Address - Fax:502-589-4799
Practice Address - Street 1:315 E BROADWAY
Practice Address - Street 2:STE 250
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3700
Practice Address - Country:US
Practice Address - Phone:502-589-4765
Practice Address - Fax:502-589-4799
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32071208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20232790AMedicaid
0007332133OtherAETNA
KY1103006Medicaid
KY64320716Medicaid
000000065792OtherANTHEM
KY0621502Medicare PIN
KY2436338000Medicare NSC
050086974Medicare PIN
000000065792OtherANTHEM
IN187540BMedicare PIN