Provider Demographics
NPI:1861495434
Name:UDALL, COLLIN (MD)
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:UDALL
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 1:3048 E BASELINE RD
Mailing Address - Street 2:STE 109
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-7286
Mailing Address - Country:US
Mailing Address - Phone:480-632-1117
Mailing Address - Fax:480-632-1118
Practice Address - Street 1:3048 E BASELINE RD
Practice Address - Street 2:STE 109
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7287
Practice Address - Country:US
Practice Address - Phone:480-632-1117
Practice Address - Fax:480-632-1118
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0878720OtherBLUE CROSS BLUE SHIELD
AZ1Z1014OtherHEALTHNET
AZ621104OtherAETNA INSURANCE
AZAZ0878720OtherBLUE CROSS BLUE SHIELD
AZZ65457Medicare PIN