Provider Demographics
NPI:1699740191
Name:COLCLASURE, DAVID SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SCOTT
Last Name:COLCLASURE
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 1:1100 MERCER AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-2303
Mailing Address - Country:US
Mailing Address - Phone:260-724-2145
Mailing Address - Fax:
Practice Address - Street 1:1100 MERCER AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-2303
Practice Address - Country:US
Practice Address - Phone:260-724-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056733207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200284220Medicaid
OH2718143Medicaid
OH2718143Medicaid
IN402730IIMedicare PIN