Provider Demographics
NPI:1972690790
Name:KOLINS, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:KOLINS
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:PO BOX 744127
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75374-4127
Mailing Address - Country:US
Mailing Address - Phone:760-739-3039
Mailing Address - Fax:972-498-9702
Practice Address - Street 1:555 EAST VALLEY PARKWAY
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025
Practice Address - Country:US
Practice Address - Phone:760-739-3030
Practice Address - Fax:760-739-2604
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34975207ZB0001X, 207ZP0102X
MI4301062799207ZP0102X, 207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G349750Medicaid
CAA46166Medicare UPIN
CA220026602Medicare PIN
CAWG34975BMedicare PIN
CA00G349750Medicaid