Provider Demographics
NPI:1376502849
Name:COLAVITA, PASQUALE A (DO)
Entity Type:Individual
Prefix:
First Name:PASQUALE
Middle Name:A
Last Name:COLAVITA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-3950
Mailing Address - Country:US
Mailing Address - Phone:215-334-3869
Mailing Address - Fax:215-755-3300
Practice Address - Street 1:2230 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19145-3950
Practice Address - Country:US
Practice Address - Phone:215-334-3869
Practice Address - Fax:215-755-3300
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008864L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016964390001Medicaid
G74037Medicare UPIN
PA011487Medicare PIN
PA0016964390001Medicaid