Provider Demographics
NPI:1295925105
Name:FRANK J COLLIE MD MEDICAL CORPORATION
Entity type:Organization
Organization Name:FRANK J COLLIE MD MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-543-8310
Mailing Address - Street 1:148 CASA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1804
Mailing Address - Country:US
Mailing Address - Phone:805-543-8310
Mailing Address - Fax:805-543-3754
Practice Address - Street 1:148 CASA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1804
Practice Address - Country:US
Practice Address - Phone:805-543-8310
Practice Address - Fax:805-543-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAZ11763207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZ11763OtherCERTIFICATE OF REGISTRATI
CA020419OtherCITY OF SAN LUIS OBISPO B
CA020419OtherCITY OF SAN LUIS OBISPO B