Provider Demographics
NPI:1184488645
Name:COLAZO, JUAN MANUEL (MD, PHD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:MANUEL
Last Name:COLAZO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 FOREST PARK AVE APT 326
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2891
Mailing Address - Country:US
Mailing Address - Phone:615-495-2276
Mailing Address - Fax:
Practice Address - Street 1:4590 NASH WAY # 90-29928
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1020
Practice Address - Country:US
Practice Address - Phone:314-362-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024020834207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery