MEDICARE: EDWIN COLON, MD PA

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	174400000X	Specialist	ME56685	FL

General Provider Information

NPI Number	:	1255640603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWIN COLON, MD PA

Provider Business Mailing Address
First Line	:	PO BOX 99
Second Line	:
City	:	DADE CITY
State	:	FL
Zip	:	33526-0099
Country	:	US
Telephone Number	:	813-929-3609
Fax Number	:	813-907-3111

Provider Business Practice Location Address
First Line	:	2407 CYPRESS RIDGE BLVD
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33544-6312
Country	:	US
Telephone Number	:	813-907-3300
Fax Number	:	813-907-3111

Authorized Official
Title or Position	:	BILLING/CREDENTIALING
Name	:	MRS. TARA DE LA CRUZ
Credential	:
Telephone Number	:	813-929-3609

Provider Enumeration Date	:	10/04/2010
Last Update Date	:	10/04/2010

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