Healthcare Provider Details

I. General information

NPI: 1780028670
Provider Name (Legal Business Name): R DEAVER COLLINS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 N STATE ST SUITE 302
JACKSON MS
39202-2413
US

IV. Provider business mailing address

1190 N STATE ST SUITE 302
JACKSON MS
39202-2413
US

V. Phone/Fax

Practice location:
  • Phone: 601-353-7090
  • Fax:
Mailing address:
  • Phone: 601-353-7090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberAC1150414
License Number StateMS

VIII. Authorized Official

Name: DR. ROBERT DEAVER COLLINS
Title or Position: PRESIDENT
Credential: MD
Phone: 601-353-7090