Provider Demographics
NPI:1932423530
Name:COLLAZO GARCIA, GEISEL RAQUEL BARBARA (MD)
Entity Type:Individual
Prefix:
First Name:GEISEL
Middle Name:RAQUEL BARBARA
Last Name:COLLAZO GARCIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:840 S WOOD ST
Mailing Address - Street 2:M/C 856
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4795
Mailing Address - Country:US
Mailing Address - Phone:312-996-7416
Mailing Address - Fax:312-413-8778
Practice Address - Street 1:1801 W TAYLOR ST
Practice Address - Street 2:SUITE 2E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-996-7416
Practice Address - Fax:312-413-8778
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036131393208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics