Healthcare Provider Details

I. General information

NPI: 1922402437
Provider Name (Legal Business Name): A.COLLAZO MD, CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE. PONCE BY PASS 2225 SUITE 409
PONCE PR
00717-1322
US

IV. Provider business mailing address

AVE. 2225 PONCE BY PASS SUITE 409
PONCE PR
00717-1322
US

V. Phone/Fax

Practice location:
  • Phone: 787-844-6165
  • Fax: 787-844-6130
Mailing address:
  • Phone: 787-844-6165
  • Fax: 787-844-6130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number6554
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number6554
License Number StatePR

VIII. Authorized Official

Name: DR. ARMANDO J COLLAZO
Title or Position: DOCTOR
Credential: MD
Phone: 787-844-6165