Provider Demographics
NPI:1386736437
Name:COLELLA, JOSEPH ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ROBERT
Last Name:COLELLA
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 1:15821 SR 525
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LANGLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98260-9780
Mailing Address - Country:US
Mailing Address - Phone:360-321-4779
Mailing Address - Fax:360-321-4782
Practice Address - Street 1:15821 SR 525
Practice Address - Street 2:SUITE 1
Practice Address - City:LANGLEY
Practice Address - State:WA
Practice Address - Zip Code:98260-9780
Practice Address - Country:US
Practice Address - Phone:360-321-4779
Practice Address - Fax:360-321-4782
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT741152W00000X
WA60279998152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT483055Medicaid
T64999Medicare UPIN
MT483055Medicaid