Provider Demographics
NPI:1023010592
Name:COLVIN, DAVID JUSTON (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JUSTON
Last Name:COLVIN
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:PO BOX 5687
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5687
Mailing Address - Country:US
Mailing Address - Phone:318-797-6661
Mailing Address - Fax:318-795-8512
Practice Address - Street 1:8383 MILLICENT WAY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-5207
Practice Address - Country:US
Practice Address - Phone:318-797-6661
Practice Address - Fax:318-795-8512
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036167418207Q00000X
LAL022840207Q00000X
IAMD-50271207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080189709OtherRR MCR
LA1494101Medicaid
5Y5296735Medicare PIN
LA1494101Medicaid