Healthcare Provider Details

I. General information

NPI: 1497946123
Provider Name (Legal Business Name): ANA MILENA COLLAZOS MARTLING M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 W HIBISCUS BLVD
MELBOURNE FL
32901
US

IV. Provider business mailing address

134 S WOODS DR
ROCKLEDGE FL
32955-3262
US

V. Phone/Fax

Practice location:
  • Phone: 321-724-5437
  • Fax: 321-724-5570
Mailing address:
  • Phone: 321-636-3066
  • Fax: 321-636-2545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA88050
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME99344
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: