Provider Demographics
NPI:1174734735
Name:COLALUCE, MARC GREGORY (DPM)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:GREGORY
Last Name:COLALUCE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Mailing Address - Street 1:5760 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-6432
Mailing Address - Country:US
Mailing Address - Phone:727-384-1111
Mailing Address - Fax:727-384-1112
Practice Address - Street 1:5760 10TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-6432
Practice Address - Country:US
Practice Address - Phone:727-384-1111
Practice Address - Fax:727-384-1112
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2815213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11010101OtherCITRUSCAID
FL21212024000OtherBEECHSTREET
FL2700633OtherUNITED
FL1734395OtherFIRST HEALTH
FL65644OtherBCBS
FL11187OtherAMERIGROUP
FL163508OtherSTAYWELL
FL59368468133733A01OtherTRICARE STANDARD PPO
FL649524OtherTUFTS
FL11010101OtherCITRUSCAID
FL649524OtherTUFTS