Healthcare Provider Details

I. General information

NPI: 1932318243
Provider Name (Legal Business Name): CLINTON WOOD COLLINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 04/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DIVISION OF UROLOGY
JACKSON MS
39216
US

IV. Provider business mailing address

2500 N STATE ST DIVISION OF UROLOGY
JACKSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5186
  • Fax: 601-984-5110
Mailing address:
  • Phone: 601-984-5186
  • Fax: 601-984-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberTL33026
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number21716
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number205946
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0101250371
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: