1568733251 NPI number — LESTER B COLLINS III MD PC

Table of content: (NPI 1568733251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568733251 NPI number — LESTER B COLLINS III MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LESTER B COLLINS III MD PC
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:
Provider Other Organization Name Type Code:
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:
1568733251
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 132419
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75713-2419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-595-2643
Provider Business Mailing Address Fax Number:
903-595-6816

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 OLYMPIC PLAZA CIR
Provider Second Line Business Practice Location Address:
SUITE 910
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75701-1951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-595-2643
Provider Business Practice Location Address Fax Number:
903-595-6816
Provider Enumeration Date:
01/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
COLLINS
Authorized Official First Name:
LESTER
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
903-595-2643

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  E4263 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 120213702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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