Provider Demographics
NPI:1568443158
Name:COLLINS, PAUL CALVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:CALVIN
Last Name:COLLINS
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:PO BOX 9515
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-9515
Mailing Address - Country:US
Mailing Address - Phone:208-287-0203
Mailing Address - Fax:208-288-5490
Practice Address - Street 1:3875 E OVERLAND RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9005
Practice Address - Country:US
Practice Address - Phone:208-287-0203
Practice Address - Fax:208-288-5490
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2013-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4426207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002753900Medicaid
IDE04221Medicare UPIN
ID002753900Medicaid