Healthcare Provider Details

I. General information

NPI: 1629120506
Provider Name (Legal Business Name): ANGELA D COLLINS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1195 N OAKLAND AVE SUITE 2
BOLIVAR MO
65613-8095
US

IV. Provider business mailing address

1500 N OAKLAND AVE
BOLIVAR MO
65613-3011
US

V. Phone/Fax

Practice location:
  • Phone: 417-777-2121
  • Fax: 417-777-2854
Mailing address:
  • Phone: 417-328-6501
  • Fax: 417-328-6338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006018403
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: