Provider Demographics
NPI:1598743221
Name:COLLACO, JOSEPHINE FRANCES (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:FRANCES
Last Name:COLLACO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 ISAAC STREETS DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3291
Mailing Address - Country:US
Mailing Address - Phone:419-698-4642
Mailing Address - Fax:419-698-8597
Practice Address - Street 1:1050 ISAAC STREETS DR
Practice Address - Street 2:SUITE 104
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3291
Practice Address - Country:US
Practice Address - Phone:419-698-4642
Practice Address - Fax:419-698-8597
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH038665207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0303942Medicaid
OH0303942Medicaid
CO1298Medicare UPIN