Provider Demographics
NPI:1811714561
Name:COLLAZO-RODRIGUEZ, BRYAN JAEL (PHD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JAEL
Last Name:COLLAZO-RODRIGUEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COAMO HOUSING BUILDING 8
Mailing Address - Street 2:APARTMENT 68
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769
Mailing Address - Country:US
Mailing Address - Phone:787-678-2765
Mailing Address - Fax:
Practice Address - Street 1:SAN JUAN VA MEDICAL CENTER 10 CASIA STREET
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:787-641-9364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program