Provider Demographics
NPI:1598754715
Name:COLLAZO, LUIS RAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:RAUL
Last Name:COLLAZO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LUIS
Other - Middle Name:RAUL
Other - Last Name:COLLAZO-RIVERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:829 N CENTER AVE
Mailing Address - Street 2:SUITE 298
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1595
Mailing Address - Country:US
Mailing Address - Phone:989-731-7708
Mailing Address - Fax:989-731-7929
Practice Address - Street 1:829 N CENTER AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1595
Practice Address - Country:US
Practice Address - Phone:989-731-7930
Practice Address - Fax:989-731-7948
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071438208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4943810Medicaid
MI3506910402OtherBCBSM