Provider Demographics
NPI:1548940182
Name:COLLAZO, NOAH JOHN
Entity type:Individual
Prefix:MR
First Name:NOAH
Middle Name:JOHN
Last Name:COLLAZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4531 SW 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-5509
Mailing Address - Country:US
Mailing Address - Phone:954-479-7011
Mailing Address - Fax:
Practice Address - Street 1:4531 SW 34TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-5509
Practice Address - Country:US
Practice Address - Phone:954-479-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program