Provider Demographics
NPI:1609850171
Name:COLLIN, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:COLLIN
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 1:8500 EXECUTIVE PARK AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2225
Mailing Address - Country:US
Mailing Address - Phone:703-698-5220
Mailing Address - Fax:703-573-2351
Practice Address - Street 1:14901 BROSCHART RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3318
Practice Address - Country:US
Practice Address - Phone:703-698-5220
Practice Address - Fax:703-573-2351
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00581562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
3137599OtherMAMSI
MD407682600Medicaid
710036OtherNCPPO
7874811OtherAETNA
DC0082OtherCAREFIRST
MD407682600Medicaid
7874811OtherAETNA