Provider Demographics
NPI:1124028378
Name:COLONNA, THERESA J (OD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:J
Last Name:COLONNA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 WESTMINSTER ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4020
Mailing Address - Country:US
Mailing Address - Phone:401-331-7850
Mailing Address - Fax:401-274-4739
Practice Address - Street 1:891 WESTMINSTER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4020
Practice Address - Country:US
Practice Address - Phone:401-331-7850
Practice Address - Fax:401-274-4739
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTA-00511152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0000029299OtherBLUE CROSS BLUE SHIELD
RI412343OtherBLUE CHIP
RI7010622Medicaid
24-62310OtherUNITED HEALTHCARE
RI30483OtherNEIGHBORHOOD HEALTH PLAN
RI7010622Medicaid
RI4816730001Medicare NSC
RI007057057Medicare PIN