Provider Demographics
NPI:1013967371
Name:COLLAZO, ANTONIO E (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:E
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:# L-3652
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-6052
Mailing Address - Country:US
Mailing Address - Phone:740-383-7927
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:990 S PROSPECT ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6283
Practice Address - Country:US
Practice Address - Phone:740-383-8060
Practice Address - Fax:740-383-7974
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35061525C207Y00000X
OH35.061525207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0827458Medicaid
647955OtherAETNA
040005658OtherTRAVELERS MEDICARE
0695991OtherPALMETTO MEDICARE
OH000000118451OtherANTHEM
1000031OtherUHC
353077OtherSUBMITTER NO.
311098079OtherPPO NEXT
311098079OtherTAX ID #
311098079041OtherCIGNA
0695991OtherPALMETTO MEDICARE
311098079OtherPPO NEXT
1000031OtherUHC