Basic Information
| Provider Information | |||||||||
| NPI: | 1003830399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 E DUPONT RD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468251601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743358700 | ||||||||
| FaxNumber: | 5743350760 | ||||||||
| Practice Location | |||||||||
| Address1: | 4420 LAKE BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197847093 | ||||||||
| FaxNumber: | 9197847395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 01070620A | IN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 35.127835 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 2009-01357 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 201050780 | 05 | IN | MEDICAID | 0060443 | 05 | OH | MEDICAID |