Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 20A7572 | CA |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 20A7572 | CA |
NPI | 1083771224 |
---|---|
Provider Name | Silvia Collazo |
First Address | Pomona, CA 91766 |
Second Address | Los Angeles, CA 90033 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2007 |
Last Update Date | 14/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00AX75720 | (05) | CA |
H56626 | (02) |