Provider Demographics
NPI:1649775990
Name:COLLINS, JAMES DEREK (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DEREK
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 1:800 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3351
Mailing Address - Country:US
Mailing Address - Phone:304-414-1880
Mailing Address - Fax:304-414-1886
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:6TH FLOOR SUPPORT TOWER
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605
Practice Address - Country:US
Practice Address - Phone:864-455-7844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC865062080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics