Provider Demographics
NPI:1952605271
Name:ROBERT A COLLEN M D MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ROBERT A COLLEN M D MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-397-0768
Mailing Address - Street 1:10802 COLLEGE PL
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-1505
Mailing Address - Country:US
Mailing Address - Phone:714-397-0768
Mailing Address - Fax:714-955-5394
Practice Address - Street 1:10802 COLLEGE PL
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-1505
Practice Address - Country:US
Practice Address - Phone:562-904-3998
Practice Address - Fax:562-924-6523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-29
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21229207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1538267125OtherTYPE 1 NPI
CAG21229Medicare PIN