Provider Demographics
NPI:1841312600
Name:COLLINS, ROGER L (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:L
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 1:1420 OLD SQUARE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211
Mailing Address - Country:US
Mailing Address - Phone:601-713-1145
Mailing Address - Fax:601-713-1106
Practice Address - Street 1:1420 OLD SQUARE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-713-1145
Practice Address - Fax:601-713-1106
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAC 8541636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS080000106Medicare ID - Type Unspecified
C47999Medicare UPIN