Provider Demographics
NPI:1023000353
Name:COLLYMORE, DAVID C (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:COLLYMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7239
Mailing Address - Country:US
Mailing Address - Phone:718-299-1100
Mailing Address - Fax:718-299-4633
Practice Address - Street 1:1776 CLAY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7239
Practice Address - Country:US
Practice Address - Phone:718-299-1100
Practice Address - Fax:718-299-4633
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225742208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00665274Medicaid
NYI00495Medicare UPIN