Provider Demographics
NPI:1578502639
Name:COLLETTI, PATRICK MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:MICHAEL
Last Name:COLLETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-8541
Mailing Address - Fax:323-442-8755
Practice Address - Street 1:1500 SAN PABLO ST FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-442-8541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31991207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G319910OtherBLUE SHIELD
CA00G319910G56OtherCAL OPTIMA
CA00G319910Medicaid
CA300031897OtherRAIL ROAD MEDICARE
CAWG31991MMedicare PIN
CAA44946Medicare UPIN
CA00G319910Medicaid
CA300031897OtherRAIL ROAD MEDICARE
CA00G319910G56OtherCAL OPTIMA