Provider Demographics
NPI:1568090371
Name:COLLAZO, ALEXANDER ANDRE
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:ANDRE
Last Name:COLLAZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3251 N MCMULLEN BOOTH RD STE 303
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2022
Mailing Address - Country:US
Mailing Address - Phone:727-725-6110
Mailing Address - Fax:
Practice Address - Street 1:36440 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-1330
Practice Address - Country:US
Practice Address - Phone:727-786-0696
Practice Address - Fax:727-669-9742
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-28
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS19753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty