Healthcare Provider Details

I. General information

NPI: 1598389702
Provider Name (Legal Business Name): ETHAN COLLIER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 GILMORE DR
AMORY MS
38821-5414
US

IV. Provider business mailing address

808 VARSITY DR
TUPELO MS
38801-4613
US

V. Phone/Fax

Practice location:
  • Phone: 662-256-3564
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29558
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: