Provider Demographics
NPI:1841350105
Name:COLLIER, MARLIN DWAYNE (MD)
Entity type:Individual
Prefix:
First Name:MARLIN
Middle Name:DWAYNE
Last Name:COLLIER
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 1:601 W LEOTA ST
Mailing Address - Street 2:PO BOX 9994
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6525
Mailing Address - Country:US
Mailing Address - Phone:308-696-8740
Mailing Address - Fax:
Practice Address - Street 1:601 W LEOTA ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6525
Practice Address - Country:US
Practice Address - Phone:308-696-8740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020978208800000X
NE28437208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000183268BMedicaid
GA000183268CMedicaid
E00405Medicare UPIN
GA000183268CMedicaid