Provider Demographics
NPI:1780955575
Name:COLLAZO OPHTHALMOLOGY & OPTOMETRY
Entity type:Organization
Organization Name:COLLAZO OPHTHALMOLOGY & OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:COLAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:215-455-1010
Mailing Address - Street 1:PO BOX 1141
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-5141
Mailing Address - Country:US
Mailing Address - Phone:215-455-1010
Mailing Address - Fax:215-732-8656
Practice Address - Street 1:4231 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-2602
Practice Address - Country:US
Practice Address - Phone:215-455-1010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE006393T207W00000X, 213E00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty