Provider Demographics
NPI:1295731156
Name:COLLINS, JEFFREY WADE (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WADE
Last Name:COLLINS
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 1:127 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45056-1548
Mailing Address - Country:US
Mailing Address - Phone:513-523-6339
Mailing Address - Fax:513-523-6330
Practice Address - Street 1:127 LYNN AVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:OH
Practice Address - Zip Code:45056-1548
Practice Address - Country:US
Practice Address - Phone:513-523-6339
Practice Address - Fax:513-523-6330
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0751726Medicaid
OHT96122Medicare UPIN
OH0651693Medicare ID - Type Unspecified