Provider Demographics
NPI:1720097660
Name:COLLINS, TERENCE ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:TERENCE
Middle Name:ROGER
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 517
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32035-0517
Mailing Address - Country:US
Mailing Address - Phone:904-548-1800
Mailing Address - Fax:904-277-7283
Practice Address - Street 1:86014 PAGES DAIRY RD
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-5203
Practice Address - Country:US
Practice Address - Phone:904-548-1880
Practice Address - Fax:904-225-0850
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271664000Medicaid
FLA38473Medicare UPIN
FL271664000Medicaid