Provider Demographics
NPI:1972714392
Name:OLD PUEBLO PLASTIC SURGERY, P.C.
Entity Type:Organization
Organization Name:OLD PUEBLO PLASTIC SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-4514
Mailing Address - Street 1:2385 N FERGUSON AVE
Mailing Address - Street 2:#101
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2385 N FERGUSON AVE
Practice Address - Street 2:#101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2835
Practice Address - Country:US
Practice Address - Phone:520-327-4514
Practice Address - Fax:520-327-8418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ135282086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty