Provider Demographics
NPI:1639139264
Name:COLLUM, EARLE SMITH (MD)
Entity Type:Individual
Prefix:DR
First Name:EARLE
Middle Name:SMITH
Last Name:COLLUM
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 27340
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85061-7340
Mailing Address - Country:US
Mailing Address - Phone:602-943-9200
Mailing Address - Fax:602-216-3000
Practice Address - Street 1:10401 W THUNDERBIRD BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3004
Practice Address - Country:US
Practice Address - Phone:623-977-7721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17037207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ111295Medicaid
AZAX4478OtherHEALTH NET AZ-PATH ASSOC
AZ1Z7112OtherHEALTH NET AZ-SUN CITY PA
AZAZ0182900OtherBCBSAZ-PATH ASSOC
AZAZ0828790OtherBCBSAZ-SUN CITY PATH
AZAZ0182900OtherBCBSAZ-PATH ASSOC
AZAX4478OtherHEALTH NET AZ-PATH ASSOC
AZZ23879Medicare PIN