=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124103759
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK A COLL O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2006
-----------------------------------------------------
Last Update Date | 07/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3720 N JOSEY LN STE 114
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75007-2470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-395-8434
-----------------------------------------------------
Fax | 972-395-8433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3611 FOXBORO LN
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75007-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-492-6920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4443T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 4443T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------