Provider Demographics
NPI:1942494299
Name:TAM, COLLIN EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:EDWARD
Last Name:TAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12918 STEEPLE CHASE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78729-7336
Mailing Address - Country:US
Mailing Address - Phone:512-331-4096
Mailing Address - Fax:
Practice Address - Street 1:4800 BURNET RD STE A-100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-2800
Practice Address - Country:US
Practice Address - Phone:512-407-9002
Practice Address - Fax:512-309-5382
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4880TG152W00000X
CA10172152W00000X
HI413152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPO80287EMedicaid
TXPO80287EMedicaid