Provider Demographics
NPI:1538259767
Name:COLO, RICHARD J (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:COLO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 MOUNTAIN ROAD
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078
Mailing Address - Country:US
Mailing Address - Phone:860-668-0266
Mailing Address - Fax:860-668-5556
Practice Address - Street 1:162 MOUNTAIN ROAD
Practice Address - Street 2:
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078
Practice Address - Country:US
Practice Address - Phone:860-668-5556
Practice Address - Fax:860-668-5556
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000736152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000736OtherST OF CT LICENSE NUMBER
CT060873489OtherTAX ID
CT004023933Medicaid
CT004023933Medicaid
CT000736OtherST OF CT LICENSE NUMBER