Provider Demographics
NPI:1316999709
Name:BARKSDALE, COLLIS L (MD)
Entity type:Individual
Prefix:
First Name:COLLIS
Middle Name:L
Last Name:BARKSDALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-8280
Mailing Address - Country:US
Mailing Address - Phone:864-365-0290
Mailing Address - Fax:
Practice Address - Street 1:290 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-8280
Practice Address - Country:US
Practice Address - Phone:864-365-0290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20594207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC205940Medicaid
SCG96102Medicare UPIN
SCG961025740Medicare PIN
SCG961029370Medicare PIN