Provider Demographics
NPI:1285619759
Name:CAROLLO, BERT (MD)
Entity type:Individual
Prefix:
First Name:BERT
Middle Name:
Last Name:CAROLLO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 S CASCADE AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1604
Mailing Address - Country:US
Mailing Address - Phone:719-866-6568
Mailing Address - Fax:719-538-2999
Practice Address - Street 1:1633 MEDICAL CENTER PT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907
Practice Address - Country:US
Practice Address - Phone:719-667-4139
Practice Address - Fax:719-473-8843
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2025-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00300722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01300722Medicaid
CO01300722Medicaid
CO16664Medicare PIN
CO01300722Medicaid