Healthcare Provider Details

I. General information

NPI: 1295747368
Provider Name (Legal Business Name): MARK JEROME COLLINS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5940 E COPPER HILL DR SUITE B
PRESCOTT VALLEY AZ
86314-2860
US

IV. Provider business mailing address

5940 E COPPER HILL DR SUITE B
PRESCOTT VALLEY AZ
86314-2860
US

V. Phone/Fax

Practice location:
  • Phone: 702-379-2227
  • Fax:
Mailing address:
  • Phone: 702-379-2227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4145
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number766
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number02847
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A12037
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: