MEDICARE: COLLIN UDALL 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	15439	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1Z1014	OTHER	AZ	HEALTHNET
3	621104	OTHER	AZ	AETNA INSURANCE

General Provider Information

NPI Number	:	1861495434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLIN UDALL M.D.

Provider Business Mailing Address
First Line	:	3048 E BASELINE RD
Second Line	:	STE 109
City	:	MESA
State	:	AZ
Zip	:	85204-7286
Country	:	US
Telephone Number	:	480-632-1117
Fax Number	:	480-632-1118

Provider Business Practice Location Address
First Line	:	3048 E BASELINE RD
Second Line	:	STE 109
City	:	MESA
State	:	AZ
Zip	:	85204-7287
Country	:	US
Telephone Number	:	480-632-1117
Fax Number	:	480-632-1118

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	09/13/2011

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Directions to “ COLLIN UDALL M.D.” Practice Location

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