Provider Demographics
NPI:1700967650
Name:COLLAZO, LOUIS MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:MANUEL
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 1:4308 ALTON RD
Mailing Address - Street 2:SUITE 620
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-4556
Mailing Address - Country:US
Mailing Address - Phone:305-777-6828
Mailing Address - Fax:305-534-1402
Practice Address - Street 1:4308 ALTON RD
Practice Address - Street 2:SUITE 620
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-4556
Practice Address - Country:US
Practice Address - Phone:305-777-6828
Practice Address - Fax:305-534-1402
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0053487207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048714799Medicaid
FLE31258Medicare UPIN
FL08214Medicare ID - Type Unspecified