Healthcare Provider Details

I. General information

NPI: 1386198976
Provider Name (Legal Business Name): CHRISTOPHER COLLAZO D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHRIS COLLAZO D.P.M.

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 VALLEY VIEW DR
MOLINE IL
61265-6152
US

IV. Provider business mailing address

2300 53RD AVE STE 100
BETTENDORF IA
52722-7565
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-3621
  • Fax:
Mailing address:
  • Phone: 563-459-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005812
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: