Provider Demographics
NPI:1356380554
Name:COLLINS, CAROLYN (MD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:310 HARTNELL AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1800
Practice Address - Country:US
Practice Address - Phone:530-244-2223
Practice Address - Fax:530-244-4799
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86623174400000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00977717OtherRAILROAD MEDICARE
CA00G866230OtherBLUE SHIELD
CAGR0054240Medicaid
CA5281634OtherAETNA
CA1629237011Medicaid
CA3469538OtherCIGNA
CACS7810Medicare PIN
CAGR0054240Medicaid
CAFJ278ZMedicare PIN
CA00G866230OtherBLUE SHIELD
CA5281634OtherAETNA
CAZZZ23157ZMedicare PIN
CAP00068472Medicare PIN