Provider Demographics
NPI:1568237063
Name:COLOSIMO, WILLIAM (RD)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:COLOSIMO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2287
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-2287
Mailing Address - Country:US
Mailing Address - Phone:716-861-4226
Mailing Address - Fax:
Practice Address - Street 1:113 COMANCHE RD
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:SD
Practice Address - Zip Code:57741-1002
Practice Address - Country:US
Practice Address - Phone:605-347-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0803133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered