Basic Information
| Provider Information | |||||||||
| NPI: | 1013967371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLAZO | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | # L-3652 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432606052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837927 | ||||||||
| FaxNumber: | 7403837942 | ||||||||
| Practice Location | |||||||||
| Address1: | 990 S PROSPECT ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433026283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403838060 | ||||||||
| FaxNumber: | 7403837974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 35061525C | OH | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 35.061525 | OH | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0827458 | 05 | OH | MEDICAID | 647955 | 01 | AETNA | OTHER | 040005658 | 01 | TRAVELERS MEDICARE | OTHER | 0695991 | 01 | PALMETTO MEDICARE | OTHER | 000000118451 | 01 | OH | ANTHEM | OTHER | 1000031 | 01 | UHC | OTHER | 353077 | 01 | SUBMITTER NO. | OTHER | 311098079 | 01 | PPO NEXT | OTHER | 311098079 | 01 | TAX ID # | OTHER | 311098079041 | 01 | CIGNA | OTHER |