Basic Information
| Provider Information | |||||||||
| NPI: | 1366446825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLON | ||||||||
| FirstName: | IVAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 REMSEN ST | ||||||||
| Address2: | FL 12 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112014333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186960186 | ||||||||
| FaxNumber: | 7186960185 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 REMSEN ST STE 1225 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112014320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6315096559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2005 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 207895 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00280160 | 05 | NY | MEDICAID |