Provider Demographics
NPI:1932482965
Name:COLLINS, CAROL FUNDAK (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:FUNDAK
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 MILLER ROAD
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012
Mailing Address - Country:US
Mailing Address - Phone:440-933-1099
Mailing Address - Fax:440-933-1040
Practice Address - Street 1:650 MILLER RD
Practice Address - Street 2:
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-2307
Practice Address - Country:US
Practice Address - Phone:440-933-1099
Practice Address - Fax:440-933-1040
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH64677207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine