Provider Demographics
NPI:1801828439
Name:COLLINS, EVAN (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:COLLINS
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 1:3498 NW FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-4441
Mailing Address - Country:US
Mailing Address - Phone:772-219-1080
Mailing Address - Fax:772-219-1070
Practice Address - Street 1:3498 NW FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4441
Practice Address - Country:US
Practice Address - Phone:772-219-1080
Practice Address - Fax:772-219-1070
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053310207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049196900Medicaid
FL07212XMedicare PIN
FLD51878Medicare UPIN