Provider Demographics
NPI:1821023334
Name:COLAIZZO, PHILIP (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:COLAIZZO
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 1:6650 W INDIANTOWN RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-4628
Mailing Address - Country:US
Mailing Address - Phone:561-575-9876
Mailing Address - Fax:561-575-2858
Practice Address - Street 1:6650 W INDIANTOWN RD
Practice Address - Street 2:SUITE 110
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-4628
Practice Address - Country:US
Practice Address - Phone:561-575-9876
Practice Address - Fax:561-575-2858
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51934208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047437100Medicaid
FL11832OtherBCBS
FL21874AMedicare ID - Type Unspecified
FL047437100Medicaid