Healthcare Provider Details

I. General information

NPI: 1053439489
Provider Name (Legal Business Name): JOHN ROBERT COLALUCA D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

898 E MAIN ST
GREENWOOD IN
46143-1407
US

IV. Provider business mailing address

PO BOX 85050
RICHMOND VA
23285-5050
US

V. Phone/Fax

Practice location:
  • Phone: 317-887-1348
  • Fax: 317-882-1631
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number0102203803
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number021805
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number020055262A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: