MEDICARE: DR. LUIS RAUL COLLAZO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	4301071438	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3506910402	OTHER	MI	BCBSM

General Provider Information

NPI Number	:	1598754715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUIS RAUL COLLAZO M.D.

Provider Business Mailing Address
First Line	:	829 N CENTER AVE
Second Line	:	SUITE 298
City	:	GAYLORD
State	:	MI
Zip	:	49735-1595
Country	:	US
Telephone Number	:	989-731-7708
Fax Number	:	989-731-7929

Provider Business Practice Location Address
First Line	:	829 N CENTER AVE
Second Line	:	SUITE 130
City	:	GAYLORD
State	:	MI
Zip	:	49735-1595
Country	:	US
Telephone Number	:	989-731-7930
Fax Number	:	989-731-7948

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	11/11/2020

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