Provider Demographics
NPI:1104887629
Name:COLLOM, KAREN S (OD)
Entity type:Individual
Prefix:DR
First Name:KAREN
Middle Name:S
Last Name:COLLOM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:3162 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-3123
Mailing Address - Country:US
Mailing Address - Phone:650-345-0248
Mailing Address - Fax:650-345-7313
Practice Address - Street 1:3162 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-3123
Practice Address - Country:US
Practice Address - Phone:650-345-0248
Practice Address - Fax:650-345-7313
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10267T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD012670OtherPTAN
1104887629OtherNPI
CASD0102670Medicaid
CASD0102670Medicaid
CAMCO644686OtherDEA#