Provider Demographics
NPI:1255640603
Name:EDWIN COLON, MD PA
Entity type:Organization
Organization Name:EDWIN COLON, MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-929-3609
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33526-0099
Mailing Address - Country:US
Mailing Address - Phone:813-929-3609
Mailing Address - Fax:813-907-3111
Practice Address - Street 1:2407 CYPRESS RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6312
Practice Address - Country:US
Practice Address - Phone:813-907-3300
Practice Address - Fax:813-907-3111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56685174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE89617Medicare UPIN