Provider Demographics
NPI:1477696490
Name:COLABELLA, DOMENIC (OD)
Entity Type:Individual
Prefix:DR
First Name:DOMENIC
Middle Name:
Last Name:COLABELLA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 E COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1224
Mailing Address - Country:US
Mailing Address - Phone:818-246-5999
Mailing Address - Fax:818-240-5757
Practice Address - Street 1:922 E COLORADO ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1224
Practice Address - Country:US
Practice Address - Phone:818-246-5999
Practice Address - Fax:818-240-5757
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT-8443T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT-08443TOtherOPTOMETRY LIC NO
CAOPT-08443TOtherOPTOMETRY LIC NO
CAOP8443Medicare ID - Type UnspecifiedPROVIDER ID NO