Provider Demographics
NPI:1053493981
Name:COLVILLE, MARTHA J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:J
Last Name:COLVILLE
Suffix:
Gender:F
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 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:15740 S OUTER 40 RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2004
Practice Address - Country:US
Practice Address - Phone:636-237-4200
Practice Address - Fax:314-364-3682
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO115117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205334709Medicaid
MO382013268Medicare PIN
MO115013230Medicare PIN
MO205334709Medicaid