Provider Demographics
NPI:1538342654
Name:WILLIAM A COLLAZO, M.D., F.A.C.C.
Entity type:Organization
Organization Name:WILLIAM A COLLAZO, M.D., F.A.C.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLLAZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-546-7699
Mailing Address - Street 1:1211 N SHARTEL AVE STE 1006
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-2433
Mailing Address - Country:US
Mailing Address - Phone:405-546-7699
Mailing Address - Fax:405-546-7795
Practice Address - Street 1:1211 N SHARTEL AVE STE 1006
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2433
Practice Address - Country:US
Practice Address - Phone:405-546-7699
Practice Address - Fax:405-546-7795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAM A COLLAZO, M.D., F.A.C.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-12
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17633207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100256940AMedicaid
OK453929709PMedicare PIN
OK100256940AMedicaid
OK700522088Medicare PIN