Provider Demographics
NPI:1700857083
Name:COLLET, JOHN B JR (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:COLLET
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-3307
Mailing Address - Country:US
Mailing Address - Phone:805-648-4105
Mailing Address - Fax:805-648-5177
Practice Address - Street 1:1643 E MAIN ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-3307
Practice Address - Country:US
Practice Address - Phone:805-648-4105
Practice Address - Fax:805-648-5177
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2675213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E26750Medicaid
CA000E26750Medicaid
1237270001Medicare NSC
CAE2675Medicare ID - Type Unspecified