MEDICARE: CAMILLE COLLETT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	1714781205	UT

General Provider Information

NPI Number	:	1275530305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMILLE COLLETT M.D.

Provider Business Mailing Address
First Line	:	1250 E 3900 S
Second Line	:	SUITE 260
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1348
Country	:	US
Telephone Number	:	801-265-2000
Fax Number	:	801-506-0296

Provider Business Practice Location Address
First Line	:	1250 E 3900 S
Second Line	:	SUITE 260
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1348
Country	:	US
Telephone Number	:	801-265-2000
Fax Number	:	801-506-0296

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	10/24/2015

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