Healthcare Provider Details

I. General information

NPI: 1063643609
Provider Name (Legal Business Name): ANTONIO J. COLORADO III M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 AVE HOSTOS
SAN JUAN PR
00918-3014
US

IV. Provider business mailing address

PO BOX 367221
SAN JUAN PR
00936-7221
US

V. Phone/Fax

Practice location:
  • Phone: 787-753-9515
  • Fax: 787-296-1691
Mailing address:
  • Phone: 787-753-9515
  • Fax: 787-296-1691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1849
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: