Provider Demographics
NPI:1295747368
Name:COLLINS, MARK JEROME (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JEROME
Last Name:COLLINS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5940 E COPPER HILL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-2860
Mailing Address - Country:US
Mailing Address - Phone:702-379-2227
Mailing Address - Fax:
Practice Address - Street 1:5940 E COPPER HILL DR
Practice Address - Street 2:SUITE B
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2860
Practice Address - Country:US
Practice Address - Phone:702-379-2227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41452084P0804X
NV7662084P0804X
IA028472084P0804X
CA20A120372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW-416OtherMEDICARE PTAN
NV002019797Medicaid
NVD0766Medicare ID - Type Unspecified
CAW-416OtherMEDICARE PTAN
E54197Medicare UPIN