Provider Demographics
NPI:1760445233
Name:COLLINS, JONATHAN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MARK
Last Name:COLLINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:7903 PROVIDENCE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-9720
Practice Address - Country:US
Practice Address - Phone:704-316-4460
Practice Address - Fax:704-316-4466
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC200001102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89131Y8Medicaid
NCNC4744AMedicare PIN
NCH70119Medicare UPIN
NC2005218Medicare ID - Type Unspecified