Provider Demographics
NPI:1912076720
Name:COLLIS, NOEL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:NOEL
Middle Name:DAVID
Last Name:COLLIS
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 1:811 2ND ST SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-3505
Mailing Address - Country:US
Mailing Address - Phone:320-632-1297
Mailing Address - Fax:
Practice Address - Street 1:811 2ND ST SE
Practice Address - Street 2:SUITE B
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3505
Practice Address - Country:US
Practice Address - Phone:320-632-1297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26373207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND25277Medicare UPIN