1477633006 NPI number — DR. DAVID P COLLETTE O.D.

Table of content: DR. DAVID P COLLETTE O.D. (NPI 1477633006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477633006 NPI number — DR. DAVID P COLLETTE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLETTE
Provider First Name:
DAVID
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477633006
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
341 PALMETTO GLEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29588-6396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-742-1006
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 DORSET ST
Provider Second Line Business Practice Location Address:
PEARLE VISION CENTER UNIVERSITY MALL
Provider Business Practice Location Address City Name:
SOUTH BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05403-6346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-658-4113
Provider Business Practice Location Address Fax Number:
802-862-8945
Provider Enumeration Date:
10/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  171 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)