Healthcare Provider Details

I. General information

NPI: 1386499770
Provider Name (Legal Business Name): MADISON COLAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2024
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3631 SE 2ND AVE
KEYSTONE HEIGHTS FL
32656-6143
US

IV. Provider business mailing address

3631 SE 2ND AVE
KEYSTONE HEIGHTS FL
32656-6143
US

V. Phone/Fax

Practice location:
  • Phone: 386-546-1637
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number39087
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: