Healthcare Provider Details

I. General information

NPI: 1134367964
Provider Name (Legal Business Name): GEORGE N COLLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2009
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 GATEWAY DR SUITE 2B
MELBOURNE FL
32901-2607
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-725-4500
  • Fax: 321-676-9731
Mailing address:
  • Phone: 321-725-4500
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME102568
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: