Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 18412 | KY |
N | 208D00000X | General Practice Physician | 18412 | KY |
NPI | 1003834540 |
---|---|
Provider Name | William Richard Colburn |
First Address | Cincinnati, OH 45263-6961 |
Second Address | Benton, KY 42025-7156 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2006 |
Last Update Date | 08/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
64184120 | (05) | KY |
C78411 | (02) |