Provider Demographics
NPI:1629034541
Name:COLLINS, BRADLEY T (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:T
Last Name:COLLINS
Suffix:
Gender:M
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:PO BOX 54877
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70154-4877
Mailing Address - Country:US
Mailing Address - Phone:504-889-7240
Mailing Address - Fax:504-889-7180
Practice Address - Street 1:4228 HOUMA BLVD
Practice Address - Street 2:SUITE 600D
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-3000
Practice Address - Country:US
Practice Address - Phone:504-885-3003
Practice Address - Fax:504-885-3004
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017242207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1358703Medicaid
LA51903DH01Medicare PIN
LA1358703Medicaid
LA5DH01Medicare PIN
B63459Medicare UPIN