Healthcare Provider Details

I. General information

NPI: 1083848899
Provider Name (Legal Business Name): LOUIS M COLLAZO MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2009
Last Update Date: 05/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4308 ALTON RD 620
MIAMI BEACH FL
33140-4556
US

IV. Provider business mailing address

4308 ALTON RD 620
MIAMI BEACH FL
33140-4556
US

V. Phone/Fax

Practice location:
  • Phone: 305-777-6828
  • Fax: 305-534-1402
Mailing address:
  • Phone: 305-777-6828
  • Fax: 305-534-1402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0053487
License Number StateFL

VIII. Authorized Official

Name: SANDRA YOLANDA GOMEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 305-777-6828