Provider Demographics
NPI:1134112667
Name:COLLAZO, ERNESTO LUIS (MD)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:LUIS
Last Name:COLLAZO
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:PO BOX 366407
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-6407
Mailing Address - Country:US
Mailing Address - Phone:787-728-3700
Mailing Address - Fax:787-728-4390
Practice Address - Street 1:1503 PROF. AUGUSTO RODRIGUEZ
Practice Address - Street 2:SEGUNDO PISO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909
Practice Address - Country:US
Practice Address - Phone:787-728-3700
Practice Address - Fax:787-728-4390
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11507207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRF49765Medicare UPIN
PR87949Medicare ID - Type Unspecified