Basic Information
| Provider Information | |||||||||
| NPI: | 1497486997 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLAZO | ||||||||
| FirstName: | MADISON | ||||||||
| MiddleName: | CAUBLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CAUBLE | ||||||||
| OtherFirstName: | MADISON | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4211 RIDGE TOP RD APT 1413 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220301103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045169736 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3300 GALLOWS RD | ||||||||
| Address2: | |||||||||
| City: | FALLS CHURCH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220423307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037764001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2022 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 0116036802 | VA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.