Healthcare Provider Details

I. General information

NPI: 1447249297
Provider Name (Legal Business Name): DR. MICHAEL JOSEPH COLLURA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 W 57TH ST SUITE 1207
NEW YORK NY
10019-2802
US

IV. Provider business mailing address

57 W 57TH ST SUITE 1207
NEW YORK NY
10019-2802
US

V. Phone/Fax

Practice location:
  • Phone: 212-980-7857
  • Fax: 212-980-7887
Mailing address:
  • Phone: 212-980-7857
  • Fax: 212-980-7887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0460351
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: