MEDICARE: DR. SANDRA E COLLAZO 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	5109TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	760681065	OTHER	TX	TAX ID

General Provider Information

NPI Number	:	1659447928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDRA E COLLAZO OD

Provider Business Mailing Address
First Line	:	9514 RIVERLAND LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77040-4374
Country	:	US
Telephone Number	:	713-827-9800
Fax Number	:	713-827-9808

Provider Business Practice Location Address
First Line	:	10488 OLD KATY RD
Second Line	:	A
City	:	HOUSTON
State	:	TX
Zip	:	77043-5106
Country	:	US
Telephone Number	:	713-827-9800
Fax Number	:	713-827-9808

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

Provider Enumeration Date	:	11/28/2006
Last Update Date	:	07/08/2007

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