Provider Demographics
NPI:1336256742
Name:COLLIE, RICHARD BRIAN (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRIAN
Last Name:COLLIE
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 1:510 CHERRY ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-3338
Mailing Address - Country:US
Mailing Address - Phone:304-324-2954
Mailing Address - Fax:304-324-2955
Practice Address - Street 1:510 CHERRY ST
Practice Address - Street 2:SUITE 205
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3338
Practice Address - Country:US
Practice Address - Phone:304-324-2954
Practice Address - Fax:304-324-2955
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDO1630207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0101252000Medicaid
F59173Medicare UPIN
WV0101252000Medicaid