Provider Demographics
NPI:1083771224
Name:COLLAZO, SILVIA (DO)
Entity Type:Individual
Prefix:
First Name:SILVIA
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 SOUTH RESERVOIR ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766
Mailing Address - Country:US
Mailing Address - Phone:909-623-3066
Mailing Address - Fax:
Practice Address - Street 1:1700 CESAR CHAVEZ AVE STE 3300
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-264-4114
Practice Address - Fax:323-264-4662
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7572207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX75720Medicaid
CA20A7572Medicare ID - Type Unspecified
H56626Medicare UPIN