Provider Demographics
NPI:1568411353
Name:COLASACCO, JAMES A (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:COLASACCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2729
Mailing Address - Country:US
Mailing Address - Phone:631-598-3434
Mailing Address - Fax:631-598-4723
Practice Address - Street 1:129 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2729
Practice Address - Country:US
Practice Address - Phone:631-598-3434
Practice Address - Fax:631-598-4723
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196657174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01760172Medicaid
NYG49893Medicare UPIN
NY01760172Medicaid