Provider Demographics
NPI:1336256130
Name:COLLISON, MARK R (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:COLLISON
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 1:105 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-2013
Mailing Address - Country:US
Mailing Address - Phone:515-321-8029
Mailing Address - Fax:
Practice Address - Street 1:405 S CLARK ST
Practice Address - Street 2:SUITE 230
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3065
Practice Address - Country:US
Practice Address - Phone:712-794-2222
Practice Address - Fax:712-792-2124
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22966207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3195875Medicaid
IA3195875Medicaid
IAI10269Medicare ID - Type Unspecified