Provider Demographics
NPI:1467507475
Name:COLATRELLA, NICHOLAS (OD FAAO)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:COLATRELLA
Suffix:
Gender:M
Credentials:OD FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 TROOP DR
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-7504
Mailing Address - Country:US
Mailing Address - Phone:320-258-3915
Mailing Address - Fax:320-258-3917
Practice Address - Street 1:2180 TROOP DR
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-7504
Practice Address - Country:US
Practice Address - Phone:320-258-3915
Practice Address - Fax:320-258-3917
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2617152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5300096700Medicaid
MN5300096700Medicaid