Provider Demographics
NPI:1164634556
Name:COLLIER PODIATRY, P.A.
Entity Type:Organization
Organization Name:COLLIER PODIATRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PETROCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:239-775-0019
Mailing Address - Street 1:1715 HERITAGE TRL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34112-8715
Mailing Address - Country:US
Mailing Address - Phone:239-775-0019
Mailing Address - Fax:239-775-0219
Practice Address - Street 1:1715 HERITAGE TRL
Practice Address - Street 2:SUITE 204
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34112-8715
Practice Address - Country:US
Practice Address - Phone:239-775-0019
Practice Address - Fax:239-775-0219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO-2399213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1811988165OtherNPI PERSONAL NUMBER
FL4574474OtherAETNA NUMBER
FLPO-2399OtherSTATE LICENSE NUMBER
FL65356AOtherBCBS NUMBER
FL340308400Medicaid
FL340308400Medicaid
FL4574474OtherAETNA NUMBER
FLPO-2399OtherSTATE LICENSE NUMBER
FL340308400Medicaid
FLDA1899Medicare PIN