Provider Demographics
NPI:1124498886
Name:COLWELL, REBECCA (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:COLWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1633 N CAPITOL AVE STE 640
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1633 N CAPITOL AVE STE 640
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1281
Practice Address - Country:US
Practice Address - Phone:317-962-8881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2022-06-06
Deactivation Date:2019-09-30
Deactivation Code:
Reactivation Date:2022-06-03
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2015026714133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered