Provider Demographics
NPI:1760477970
Name:COLLINGWOOD, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:COLLINGWOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4411 THE 25 WAY NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-5857
Mailing Address - Country:US
Mailing Address - Phone:505-332-5800
Mailing Address - Fax:505-332-6921
Practice Address - Street 1:4411 THE 25 WAY NE
Practice Address - Street 2:SUITE 150
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5857
Practice Address - Country:US
Practice Address - Phone:505-332-5800
Practice Address - Fax:505-332-6921
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010343322085N0700X, 2085R0202X
NMMD2007-01032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59629835Medicaid
IN100353300Medicaid
NM59629835Medicaid
E03693Medicare UPIN
IN100353300Medicaid