Provider Demographics
NPI:1750498242
Name:RODRIGUEZ-COLLAZO, EDGARDO (DPM)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:
Last Name:RODRIGUEZ-COLLAZO
Suffix:
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 1:558 WEST FULLERTON PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5919
Mailing Address - Country:US
Mailing Address - Phone:312-335-3939
Mailing Address - Fax:312-335-5469
Practice Address - Street 1:2913 N COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6211
Practice Address - Country:US
Practice Address - Phone:312-335-3939
Practice Address - Fax:312-335-5469
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004892213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1623349OtherBCBS OF IL
IL0160048923Medicaid
5932260Medicare ID - Type Unspecified
IL0160048923Medicaid