Provider Demographics
NPI:1740251008
Name:D'ALTILIO, COLETTE TARA (DPM)
Entity type:Individual
Prefix:DR
First Name:COLETTE
Middle Name:TARA
Last Name:D'ALTILIO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 E SAMPLE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LIGHTHOUSE POINT
Mailing Address - State:FL
Mailing Address - Zip Code:33064-7596
Mailing Address - Country:US
Mailing Address - Phone:954-933-9033
Mailing Address - Fax:954-934-0060
Practice Address - Street 1:2100 E SAMPLE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-7574
Practice Address - Country:US
Practice Address - Phone:954-933-9033
Practice Address - Fax:954-934-0060
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3030213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3405150-00Medicaid
FL3405150-00Medicaid