Healthcare Provider Details

I. General information

NPI: 1417606187
Provider Name (Legal Business Name): NICHOLAS ANTHONY COLALUCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 CLYDE MORRIS BLVD STE 330
ORMOND BEACH FL
32174-3114
US

IV. Provider business mailing address

345 CLYDE MORRIS BLVD STE 330
ORMOND BEACH FL
32174-3114
US

V. Phone/Fax

Practice location:
  • Phone: 386-672-4244
  • Fax: 386-672-0603
Mailing address:
  • Phone: 386-672-4244
  • Fax: 386-672-0603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME179315
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: