MEDICARE: DR. SHELBY COLLYMORE DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	V1058	TX

General Provider Information

NPI Number	:	1215515887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHELBY COLLYMORE DO

Provider Business Mailing Address
First Line	:	2626 SOUTH CARRIER PKWY
Second Line	:	ST. 300
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-5014
Country	:	US
Telephone Number	:	972-642-7337
Fax Number	:	972-642-7339

Provider Business Practice Location Address
First Line	:	2626 SOUTH CARRIER PKWY
Second Line	:	STE. 300
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-5014
Country	:	US
Telephone Number	:	972-642-7337
Fax Number	:	972-642-7339

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2021
Last Update Date	:	07/15/2024

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