Provider Demographics
NPI:1245232065
Name:COLLADA, MAURICE JR (MD)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:COLLADA
Suffix:JR
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 1:875 OAK ST SE STE 5060
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3987
Mailing Address - Country:US
Mailing Address - Phone:503-399-1386
Mailing Address - Fax:503-399-1182
Practice Address - Street 1:875 OAK ST SE STE 5060
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3987
Practice Address - Country:US
Practice Address - Phone:503-399-1386
Practice Address - Fax:503-399-1182
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13614174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR200709Medicaid
OR200709Medicaid
ORC94178Medicare UPIN