Provider Demographics
NPI:1922402437
Name:A.COLLAZO MD, CSP
Entity Type:Organization
Organization Name:A.COLLAZO MD, CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ARMANDO
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLLAZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-844-6165
Mailing Address - Street 1:AVE. 2225 PONCE BY PASS
Mailing Address - Street 2:SUITE 409
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-1322
Mailing Address - Country:US
Mailing Address - Phone:787-844-6165
Mailing Address - Fax:787-844-6130
Practice Address - Street 1:AVE. PONCE BY PASS 2225
Practice Address - Street 2:SUITE 409
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1322
Practice Address - Country:US
Practice Address - Phone:787-844-6165
Practice Address - Fax:787-844-6130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6554261QM2500X, 302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR27003Medicare PIN
PRC79608Medicare UPIN