Provider Demographics
NPI:1336106277
Name:COLELLA, MARIO RICCARDO (DO)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:RICCARDO
Last Name:COLELLA
Suffix:
Gender:M
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6450
Mailing Address - Fax:414-805-6464
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6450
Practice Address - Fax:414-805-6464
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDH0060361207PE0004X
WI50358207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1336106277Medicaid
WI1336106277Medicaid
WI1032 73-601Medicare PIN