Provider Demographics
NPI:1295931434
Name:RICHARD D. COLLISON, M.D.,P.C.
Entity type:Organization
Organization Name:RICHARD D. COLLISON, M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:COLLISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-778-5443
Mailing Address - Street 1:PO BOX 2860
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86302-2860
Mailing Address - Country:US
Mailing Address - Phone:928-778-5443
Mailing Address - Fax:928-443-1572
Practice Address - Street 1:1003 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1641
Practice Address - Country:US
Practice Address - Phone:928-778-5443
Practice Address - Fax:928-443-1572
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD COLLISON MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-25
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15632207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1669448395OtherINDIVIDUAL NPI NEED GRP
AZ249559Medicaid
AZ1669448395OtherINDIVIDUAL NPI NEED GRP
AZWMBHVMedicare ID - Type UnspecifiedMEDIARE PROVIDER #