Provider Demographics
NPI:1124288428
Name:COLBERT, MARIAN (LMT)
Entity type:Individual
Prefix:MRS
First Name:MARIAN
Middle Name:
Last Name:COLBERT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18313 USEPPA ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-5436
Mailing Address - Country:US
Mailing Address - Phone:239-218-2310
Mailing Address - Fax:
Practice Address - Street 1:5117 CASTELLO DR STE 2
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-1925
Practice Address - Country:US
Practice Address - Phone:239-218-2310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA35406171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC9444OtherBSBCFL