Provider Demographics
NPI:1710434576
Name:COLLAZO, JOAQUIN
Entity Type:Individual
Prefix:
First Name:JOAQUIN
Middle Name:
Last Name:COLLAZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DG3 CALLE PRADERAS
Mailing Address - Street 2:VALLE VERDE III (NORTH)
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961
Mailing Address - Country:US
Mailing Address - Phone:787-632-7852
Mailing Address - Fax:
Practice Address - Street 1:DG3 CALLE PRADERAS
Practice Address - Street 2:VALLE VERDE III (NORTH)
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-632-7852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program