1710065040 NPI number — JEFFREY W. COLLINS, O.D., INC.

Table of content: (NPI 1710065040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710065040 NPI number — JEFFREY W. COLLINS, O.D., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY W. COLLINS, O.D., INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SUZANNE L. LEACH O.D. FAMILY VISION CARE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710065040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1845 STATE ROUTE 127 N
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
EATON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45320-9284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-472-5665
Provider Business Mailing Address Fax Number:
937-472-3933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1845 STATE ROUTE 127 N
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
EATON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45320-9284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-472-5665
Provider Business Practice Location Address Fax Number:
937-472-3933
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEACH
Authorized Official First Name:
SUZANNE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
937-472-5665

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4119 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: T938 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 1156 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0230824 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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