Basic Information
| Provider Information | |||||||||
| NPI: | 1982691945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3455 TABLE MESA DR APT B116 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803055833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143025265 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4590 W 121ST AVE | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800205666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034394544 | ||||||||
| FaxNumber: | 3034399369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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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 | 207P00000X | 35062911C | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.