Provider Demographics
NPI:1801195565
Name:COLLAZO, TYSON HERZOG (MD)
Entity Type:Individual
Prefix:DR
First Name:TYSON
Middle Name:HERZOG
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 1:111 OSBORNE ST FL 2
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6000
Mailing Address - Country:US
Mailing Address - Phone:203-739-7038
Mailing Address - Fax:
Practice Address - Street 1:111 OSBORNE ST FL 2
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-739-7038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269178207RG0100X
PAMD469399207RG0100X
CT76586207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology