Provider Demographics
NPI:1174611511
Name:COLLINS, KEVIN B (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:B
Last Name:COLLINS
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:PO BOX 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-936-7000
Mailing Address - Fax:870-934-3677
Practice Address - Street 1:1109 E REELFOOT AVE STE F
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5867
Practice Address - Country:US
Practice Address - Phone:731-884-1412
Practice Address - Fax:731-884-1720
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND81832085R0001X
MS279892085R0001X
TN575532085R0001X
MO1114632085R0001X
ARE-07292085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10859Medicaid
ND17687Medicare ID - Type Unspecified
ND10859Medicaid
G23581Medicare UPIN