Provider Demographics
NPI:1578659249
Name:COLLEN, MARTIN JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JAY
Last Name:COLLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6647 HAWARDEN DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-5111
Mailing Address - Country:US
Mailing Address - Phone:951-789-1483
Mailing Address - Fax:951-789-7610
Practice Address - Street 1:36320 INLAND VALLEY DR
Practice Address - Street 2:STE. 209
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7512
Practice Address - Country:US
Practice Address - Phone:951-203-1538
Practice Address - Fax:951-789-7610
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G210320207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G210320Medicare ID - Type Unspecified
CAD83927Medicare UPIN