Provider Demographics
NPI:1679700579
Name:MARTIN J. COLLEN M.D. INC.
Entity Type:Organization
Organization Name:MARTIN J. COLLEN M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-271-2237
Mailing Address - Street 1:7120 INDIANA AVE STE G
Mailing Address - Street 2:PMB 81
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-4500
Mailing Address - Country:US
Mailing Address - Phone:951-891-1483
Mailing Address - Fax:
Practice Address - Street 1:6647 HAWARDEN DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-5111
Practice Address - Country:US
Practice Address - Phone:951-203-1538
Practice Address - Fax:951-789-7610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G210320207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G210320Medicare PIN
CAD83927Medicare UPIN