Healthcare Provider Details

I. General information

NPI: 1790604056
Provider Name (Legal Business Name): MR. RICARDO COLLAZO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 S UNIVERSITY DR
FT LAUDERDALE FL
33328-2004
US

IV. Provider business mailing address

2881 SW 73RD WAY APT 2105
DAVIE FL
33314-1023
US

V. Phone/Fax

Practice location:
  • Phone: 800-541-6682
  • Fax:
Mailing address:
  • Phone: 787-673-1455
  • Fax: 787-673-1455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: