Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 036647 | CT |
NPI | 1053396341 |
---|---|
Provider Name | John W Colberg |
First Address | New Haven, CT 06536-0805 |
Second Address | New Haven, CT 06519-1369 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/12/2005 |
Last Update Date | 25/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001366477 | (05) | CT |
E66014 | (02) |