Provider Demographics
NPI:1215199294
Name:COLLAZOS-RODRIGUEZ, JUAN C (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:COLLAZOS-RODRIGUEZ
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 1:4695 MANDERLY DR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33449-7406
Mailing Address - Country:US
Mailing Address - Phone:702-756-9994
Mailing Address - Fax:561-484-5752
Practice Address - Street 1:1410 ROYAL PALM BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-1608
Practice Address - Country:US
Practice Address - Phone:561-777-5246
Practice Address - Fax:561-484-5752
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME131002208000000X
NV14039208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1215199294Medicaid
NV1215199294Medicaid