=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023068343
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH CLYDE COLLINS DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 12/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2724 W THOMAS RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85017-5514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-353-1166
-----------------------------------------------------
Fax | 602-353-1188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 257 N HORNE
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85203-7930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-969-5250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | DO3858
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------