Provider Demographics
NPI:1619531027
Name:COLLAZO, SERGIO (MD)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:COLLAZO
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 1:2931 W HILLSBOROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-6054
Mailing Address - Country:US
Mailing Address - Phone:813-930-0930
Mailing Address - Fax:813-930-0950
Practice Address - Street 1:2931 W HILLSBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-6054
Practice Address - Country:US
Practice Address - Phone:813-930-0930
Practice Address - Fax:813-930-0950
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1172208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice