Healthcare Provider Details

I. General information

NPI: 1245286905
Provider Name (Legal Business Name): GARY B COLLINS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 12/28/2024
Certification Date: 12/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST.-MS 11502V HEALTHPARTNERS REGIONS SPECIALTY CLINICS
ST. PAUL MN
55101-2502
US

IV. Provider business mailing address

1000 GREENLEY RD
SONORA CA
95370-5200
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-4870
  • Fax: 651-254-4870
Mailing address:
  • Phone: 209-536-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number66130-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: