Provider Demographics
NPI:1912909516
Name:COLLETT, JEFFREY P (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:P
Last Name:COLLETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-6413
Mailing Address - Country:US
Mailing Address - Phone:641-682-8571
Mailing Address - Fax:641-682-8573
Practice Address - Street 1:1005 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-6413
Practice Address - Country:US
Practice Address - Phone:641-682-8571
Practice Address - Fax:641-682-8573
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2087152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2157651Medicaid
IA2157651Medicaid
IA47602Medicare ID - Type Unspecified