Healthcare Provider Details

I. General information

NPI: 1760673107
Provider Name (Legal Business Name): JEANNETTE ELISE COLON-MARIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 WALL ST UNIT A
VALPARAISO IN
46383-2585
US

IV. Provider business mailing address

401 WALL ST UNIT A
VALPARAISO IN
46383-2585
US

V. Phone/Fax

Practice location:
  • Phone: 219-707-5772
  • Fax: 219-707-5758
Mailing address:
  • Phone: 219-707-5772
  • Fax: 219-707-5758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number17073
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01075122A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: