Provider Demographics
NPI:1225179302
Name:COLLAZO, PEDRO RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PEDRO
Middle Name:RAFAEL
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 5216
Mailing Address - Street 2:ATOCHA STATION
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00733-5216
Mailing Address - Country:US
Mailing Address - Phone:787-284-5514
Mailing Address - Fax:787-259-0206
Practice Address - Street 1:2321 CALLE UNIVERSIDAD
Practice Address - Street 2:PH-1
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717
Practice Address - Country:US
Practice Address - Phone:787-381-1086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH-67979Medicare UPIN
PR2-0542Medicare ID - Type UnspecifiedSSS