Healthcare Provider Details

I. General information

NPI: 1689295842
Provider Name (Legal Business Name): COLLIN GABRIEL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 E MAIN ST
LANCASTER OH
43130-4056
US

IV. Provider business mailing address

1155 E MAIN ST
LANCASTER OH
43130-4056
US

V. Phone/Fax

Practice location:
  • Phone: 740-689-6758
  • Fax: 740-689-6759
Mailing address:
  • Phone: 740-689-6758
  • Fax: 740-689-6759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58031790
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: