Provider Demographics
NPI:1942209077
Name:WM COLANTONI JR MD PC
Entity Type:Organization
Organization Name:WM COLANTONI JR MD PC
Other - Org Name:WILLIAM COLANTONI JR MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:COLANTONI
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:563-386-3333
Mailing Address - Street 1:100 E KIMBERLY RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-5924
Mailing Address - Country:US
Mailing Address - Phone:563-386-3333
Mailing Address - Fax:563-386-9209
Practice Address - Street 1:100 E KIMBERLY RD
Practice Address - Street 2:SUITE 303
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5924
Practice Address - Country:US
Practice Address - Phone:563-386-3333
Practice Address - Fax:563-386-9209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20388207N00000X
IL036-054040207N00000X
NE12808207N00000X
CAG833882207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2131318Medicaid
B18012Medicare UPIN
IA19046Medicare PIN