Provider Demographics
NPI:1710065040
Name:JEFFREY W. COLLINS, O.D., INC.
Entity Type:Organization
Organization Name:JEFFREY W. COLLINS, O.D., INC.
Other - Org Name:SUZANNE L. LEACH O.D. FAMILY VISION CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-472-5665
Mailing Address - Street 1:1845 STATE ROUTE 127 N
Mailing Address - Street 2:STE A
Mailing Address - City:EATON
Mailing Address - State:OH
Mailing Address - Zip Code:45320-9284
Mailing Address - Country:US
Mailing Address - Phone:937-472-5665
Mailing Address - Fax:937-472-3933
Practice Address - Street 1:1845 STATE ROUTE 127 N
Practice Address - Street 2:STE A
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-9284
Practice Address - Country:US
Practice Address - Phone:937-472-5665
Practice Address - Fax:937-472-3933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4119152W00000X
OHT938152W00000X
OH1156152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0230824Medicaid
OH0230824Medicaid