Provider Demographics
NPI:1982691945
Name:COLLINS, MARK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
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 1:3455 TABLE MESA DR APT B116
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-5833
Mailing Address - Country:US
Mailing Address - Phone:614-302-5265
Mailing Address - Fax:
Practice Address - Street 1:4590 W 121ST AVE
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-5666
Practice Address - Country:US
Practice Address - Phone:303-439-4544
Practice Address - Fax:303-439-9369
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35062911C207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E88263Medicare UPIN
OHCO085730Medicare ID - Type Unspecified