Provider Demographics
NPI:1730144627
Name:COLAVITA, RICHARD D (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
Last Name:COLAVITA
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 1:285 DAVIDSON AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-4153
Mailing Address - Country:US
Mailing Address - Phone:732-271-1400
Mailing Address - Fax:732-271-3543
Practice Address - Street 1:285 DAVIDSON AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-4153
Practice Address - Country:US
Practice Address - Phone:732-271-1400
Practice Address - Fax:732-271-3543
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA51220207L00000X
NJ25MA05122000207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1788205M1JOtherMEDICARE PTAN
NJ4543631Medicaid
NJ4543631Medicaid