Healthcare Provider Details

I. General information

NPI: 1720097660
Provider Name (Legal Business Name): TERENCE ROGER COLLINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86014 PAGES DAIRY RD
YULEE FL
32097-5203
US

IV. Provider business mailing address

PO BOX 517
FERNANDINA BEACH FL
32035-0517
US

V. Phone/Fax

Practice location:
  • Phone: 904-548-1880
  • Fax: 904-225-0850
Mailing address:
  • Phone: 904-548-1800
  • Fax: 904-277-7283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME39441
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: