Provider Demographics
NPI:1083848899
Name:LOUIS M COLLAZO MD PA
Entity Type:Organization
Organization Name:LOUIS M COLLAZO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:YOLANDA
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-777-6828
Mailing Address - Street 1:4308 ALTON RD
Mailing Address - Street 2:620
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-4556
Mailing Address - Country:US
Mailing Address - Phone:305-777-6828
Mailing Address - Fax:305-534-1402
Practice Address - Street 1:4308 ALTON RD
Practice Address - Street 2:620
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-4556
Practice Address - Country:US
Practice Address - Phone:305-777-6828
Practice Address - Fax:305-534-1402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-07
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053487174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE31258Medicare UPIN