Provider Demographics
NPI:1801882329
Name:COLLINI, MICHAEL P (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:COLLINI
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 1:5001 S COOPER ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5993
Mailing Address - Country:US
Mailing Address - Phone:866-367-8768
Mailing Address - Fax:817-541-9555
Practice Address - Street 1:7100 OAKMONT BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3908
Practice Address - Country:US
Practice Address - Phone:866-367-8768
Practice Address - Fax:817-541-9501
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5557208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113290405OtherMEDICAID OTHER
TX113290406Medicaid
TX113290402Medicaid
TX113290403Medicaid
TX113290404Medicaid
TX8K6987Medicare PIN
TX113290403Medicaid
TX113290404Medicaid
TX113290402Medicaid