Basic Information
| Provider Information | |||||||||
| NPI: | 1538259767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLO | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 162 MOUNTAIN ROAD | ||||||||
| Address2: | |||||||||
| City: | SUFFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606680266 | ||||||||
| FaxNumber: | 8606685556 | ||||||||
| Practice Location | |||||||||
| Address1: | 162 MOUNTAIN ROAD | ||||||||
| Address2: | |||||||||
| City: | SUFFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606685556 | ||||||||
| FaxNumber: | 8606685556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 07/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 000736 | CT | Y | Eye and Vision Services Providers | Optometrist | 152WC0802X | 000736 | CT | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
ID Information
| ID | Type | State | Issuer | Description | 000736 | 01 | CT | ST OF CT LICENSE NUMBER | OTHER | 060873489 | 01 | CT | TAX ID | OTHER | 004023933 | 05 | CT | MEDICAID |