MEDICARE: DR. KAREN S COLLOM OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	10267T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SD012670	OTHER	CA	PTAN
2	1104887629	OTHER		NPI
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104887629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAREN S COLLOM OD

Provider Business Mailing Address
First Line	:	3162 CAMPUS DR
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-3123
Country	:	US
Telephone Number	:	650-345-0248
Fax Number	:	650-345-7313

Provider Business Practice Location Address
First Line	:	3162 CAMPUS DR
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-3123
Country	:	US
Telephone Number	:	650-345-0248
Fax Number	:	650-345-7313

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2006
Last Update Date	:	03/07/2023

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