Provider Demographics
NPI:1790721371
Name:COLLIN, CHARLES FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:FREDERICK
Last Name:COLLIN
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 1:1918 RANDOLPH RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1100
Mailing Address - Country:US
Mailing Address - Phone:704-364-8100
Mailing Address - Fax:704-364-2073
Practice Address - Street 1:1918 RANDOLPH RD
Practice Address - Street 2:SUITE 500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1100
Practice Address - Country:US
Practice Address - Phone:704-364-8100
Practice Address - Fax:704-365-2073
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30897208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8923803Medicaid
C83303Medicare UPIN
NC8923803Medicaid