Provider Demographics
NPI:1134367964
Name:COLLIS, GEORGE N (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:N
Last Name:COLLIS
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-725-4500
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1223 GATEWAY DR
Practice Address - Street 2:SUITE 2B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-725-4500
Practice Address - Fax:321-676-9731
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1025682086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015353800Medicaid
FLIF391ZOtherMEDICARE
FLIF391YOtherMEDICARE