Provider Demographics
NPI:1144482167
Name:COLACO, SHANTHI MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:SHANTHI
Middle Name:MARIE
Last Name:COLACO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2990 S SEPULVEDA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-0002
Mailing Address - Country:US
Mailing Address - Phone:323-421-4747
Mailing Address - Fax:
Practice Address - Street 1:2990 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-0002
Practice Address - Country:US
Practice Address - Phone:323-421-4747
Practice Address - Fax:949-955-7351
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA123314207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB250970Medicare PIN