Basic Information
| Provider Information | |||||||||
| NPI: | 1801195565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLAZO | ||||||||
| FirstName: | TYSON | ||||||||
| MiddleName: | HERZOG | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1554 | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117940989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314440650 | ||||||||
| FaxNumber: | 6316384170 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 TECHNOLOGY DR | ||||||||
| Address2: | |||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117334064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314445220 | ||||||||
| FaxNumber: | 6314445225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 269178 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.