Provider Demographics
NPI:1194744847
Name:COLBURN, WILLIAM J (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:COLBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21114 VANOWEN ST
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-2821
Mailing Address - Country:US
Mailing Address - Phone:818-992-7848
Mailing Address - Fax:818-992-7748
Practice Address - Street 1:21114 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-2821
Practice Address - Country:US
Practice Address - Phone:818-992-7848
Practice Address - Fax:818-992-7748
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33324174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG33324OtherLICENSE
CAA45506Medicare UPIN
CAWG33324JMedicare PIN
CAWG33324KMedicare PIN
CAWG33324IMedicare PIN