Provider Demographics
NPI:1780886770
Name:COLLINS, ETHELDREDA LANCASTER (MD)
Entity type:Individual
Prefix:
First Name:ETHELDREDA
Middle Name:LANCASTER
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ETHELDREDA
Other - Middle Name:LANCASTER
Other - Last Name:COLLINS - BAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:42 E PARKWAY N
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42 E PARKWAY N
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3039
Practice Address - Country:US
Practice Address - Phone:901-365-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-03
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26038207R00000X
NC200400317207R00000X
MI4301093879207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine