Provider Demographics
NPI:1497719157
Name:COLLINS, BRENT C (OD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:C
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 1:1609 WOODRUFF RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5928
Mailing Address - Country:US
Mailing Address - Phone:864-288-7445
Mailing Address - Fax:864-288-8288
Practice Address - Street 1:1609 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5928
Practice Address - Country:US
Practice Address - Phone:864-288-7445
Practice Address - Fax:864-288-8288
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC-1142152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD11565Medicaid
SCD11565Medicaid