Provider Demographics
NPI:1598917700
Name:COLLAZO, GRETCHEN (MD)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:COLLAZO
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 1:3 SECTOR CARRASQUILLO
Mailing Address - Street 2:SECTOR MARCELINO CARRASQUILLO
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771
Mailing Address - Country:US
Mailing Address - Phone:787-421-3783
Mailing Address - Fax:
Practice Address - Street 1:DEPARTAMENTO MEDICINA DE FAMILIA Y GERIATRIA
Practice Address - Street 2:CALL BOX 6021
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00984-0215
Practice Address - Country:US
Practice Address - Phone:787-776-4420
Practice Address - Fax:787-776-4421
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12,296I207Q00000X
PR28,187R207Q00000X
PR28,413R207Q00000X
PR28,794R207Q00000X
PR20585207QG0300X
PR12,102I284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No284300000XHospitalsSpecial Hospital