Healthcare Provider Details

I. General information

NPI: 1720076086
Provider Name (Legal Business Name): NICOLAS M COLORADO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 OAKFIELD DR
BRANDON FL
33511-5700
US

IV. Provider business mailing address

507 OAKFIELD DR
BRANDON FL
33511-5700
US

V. Phone/Fax

Practice location:
  • Phone: 813-661-6667
  • Fax:
Mailing address:
  • Phone: 813-661-6667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME 58387
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: