Healthcare Provider Details

I. General information

NPI: 1477017242
Provider Name (Legal Business Name): SAMUEL ANTONIO COLLAZO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 03/29/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3459 5TH AVE # NW628
PITTSBURGH PA
15213-3236
US

IV. Provider business mailing address

3600 FORBES AVE STE 140
PITTSBURGH PA
15213-3410
US

V. Phone/Fax

Practice location:
  • Phone: 412-692-2212
  • Fax:
Mailing address:
  • Phone: 412-692-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: