Provider Demographics
NPI:1891088738
Name:COLORATO, IVAN S
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:S
Last Name:COLORATO
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 1:5727 DEER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-2112
Mailing Address - Country:US
Mailing Address - Phone:630-663-9306
Mailing Address - Fax:
Practice Address - Street 1:314 W ARMY TRAIL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2300
Practice Address - Country:US
Practice Address - Phone:630-893-5382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-25
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051287590183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist