Basic Information
| Provider Information | |||||||||
| NPI: | 1972525608 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLLIER | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1912 PORT WEYBRIDGE PL | ||||||||
| Address2: | |||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926605143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492943074 | ||||||||
| FaxNumber: | 9496444485 | ||||||||
| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584475 | ||||||||
| FaxNumber: | 9095584143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 09/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 20A5308 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00AX53080 | 05 | CA | MEDICAID |