Provider Demographics
NPI:1952531378
Name:COLARCO, JUSTIN (DPM)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:COLARCO
Suffix:
Gender:M
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-877-5199
Mailing Address - Fax:702-877-2692
Practice Address - Street 1:4750 W OAKEY BLVD STE 1A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1535
Practice Address - Country:US
Practice Address - Phone:702-877-8625
Practice Address - Fax:702-877-2692
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0905213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1952531378Medicaid
NVC1502ZMedicare PIN