Provider Demographics
NPI:1942356548
Name:COLLIER, AVANTA (MD)
Entity Type:Individual
Prefix:
First Name:AVANTA
Middle Name:
Last Name:COLLIER
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 1:12462 PUTNAM ST
Mailing Address - Street 2:UNIT 501
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90602-1048
Mailing Address - Country:US
Mailing Address - Phone:562-789-5429
Mailing Address - Fax:562-789-4441
Practice Address - Street 1:12462 PUTNAM ST
Practice Address - Street 2:UNIT 501
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1048
Practice Address - Country:US
Practice Address - Phone:562-789-5429
Practice Address - Fax:562-789-4441
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA62961207N00000X
CAC131378207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109710AMedicaid
GA003109710AMedicaid