Provider Demographics
NPI:1124103759
Name:COLL, MARK A (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:COLL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 FOXBORO LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-2937
Mailing Address - Country:US
Mailing Address - Phone:972-492-6920
Mailing Address - Fax:
Practice Address - Street 1:3720 N JOSEY LN STE 114
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-2470
Practice Address - Country:US
Practice Address - Phone:972-395-8434
Practice Address - Fax:972-395-8433
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4443T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G4180Medicare ID - Type UnspecifiedINDIVIDUAL ID
TXX81421Medicare UPIN