Provider Demographics
NPI:1285813071
Name:MAURICE COLLADA JR. MD PC
Entity type:Organization
Organization Name:MAURICE COLLADA JR. MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPAETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-581-5517
Mailing Address - Street 1:1344 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4283
Mailing Address - Country:US
Mailing Address - Phone:503-581-5517
Mailing Address - Fax:503-581-6341
Practice Address - Street 1:1344 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4283
Practice Address - Country:US
Practice Address - Phone:503-581-5517
Practice Address - Fax:503-581-6341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13614174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
103728OtherMEDICARE
OR5459030001Medicare NSC
ORC94178Medicare UPIN