Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207W00000X | Ophthalmologist | IL |
NPI | 1023012614 |
---|---|
Provider Name | Dr. Edward Leslie Colloton |
First Address | Bloomington, IL 61701-7910 |
Second Address | Bloomington, IL 61701-7910 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
05700231 | BC/BS PROVIDER # (01) | IL |
A03383 | (02) | IL |