Provider Demographics
NPI:1043226079
Name:COLLETTI, D.C., JOHN J (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:COLLETTI, D.C.
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790-4315
Mailing Address - Country:US
Mailing Address - Phone:508-636-3731
Mailing Address - Fax:508-636-3741
Practice Address - Street 1:829 MAIN RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:MA
Practice Address - Zip Code:02790-4315
Practice Address - Country:US
Practice Address - Phone:508-636-3731
Practice Address - Fax:508-636-3741
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA277111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAT57948Medicare UPIN
MAY35014Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE