Healthcare Provider Details

I. General information

NPI: 1598917700
Provider Name (Legal Business Name): GRETCHEN COLLAZO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTAMENTO MEDICINA DE FAMILIA Y GERIATRIA CALL BOX 6021
CAROLINA PR
00984-0215
US

IV. Provider business mailing address

3 SECTOR CARRASQUILLO SECTOR MARCELINO CARRASQUILLO
LAS PIEDRAS PR
00771
US

V. Phone/Fax

Practice location:
  • Phone: 787-776-4420
  • Fax: 787-776-4421
Mailing address:
  • Phone: 787-421-3783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12,296I
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28,187R
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28,413R
License Number StatePR
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number28,794R
License Number StatePR
# 5
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number20585
License Number StatePR
# 6
Primary TaxonomyN
Taxonomy Code284300000X
TaxonomySpecial Hospital
License Number12,102I
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: