Provider Demographics
NPI:1225144124
Name:COLLETTO, BRIAN (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:COLLETTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-4064
Mailing Address - Country:US
Mailing Address - Phone:803-980-3937
Mailing Address - Fax:803-980-5353
Practice Address - Street 1:356 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4064
Practice Address - Country:US
Practice Address - Phone:803-980-3937
Practice Address - Fax:803-980-5353
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1202152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD12029Medicaid
SCU86592Medicare UPIN