Provider Demographics
NPI:1356379721
Name:COLLINGHAM, JOHN RICHARD (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:COLLINGHAM
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 1:8170 OLD CARRIAGE CT STE 100
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-3164
Mailing Address - Country:US
Mailing Address - Phone:952-428-3600
Mailing Address - Fax:952-428-3636
Practice Address - Street 1:2000 NORTH AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-1498
Practice Address - Country:US
Practice Address - Phone:507-646-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46339207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH18346Medicare UPIN