Provider Demographics
NPI:1245248566
Name:BADILLO COLLAZO, MANUEL A (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:A
Last Name:BADILLO 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 1:101PITIRRE
Mailing Address - Street 2:MONTEHIEDRA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-774-0692
Mailing Address - Fax:787-706-9112
Practice Address - Street 1:21 ST 3S3
Practice Address - Street 2:LAS LOMAS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:787-774-0692
Practice Address - Fax:787-706-9112
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR12083207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR88466Medicare PIN
PR88466Medicare ID - Type Unspecified
PRG41199Medicare UPIN