Provider Demographics
NPI:1093795387
Name:JAMBOR, COLLEEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:J
Last Name:JAMBOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:33 DALE ROAD
Mailing Address - Street 2:STE 1
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001
Mailing Address - Country:US
Mailing Address - Phone:860-678-1800
Mailing Address - Fax:508-829-5367
Practice Address - Street 1:33 DALE ROAD
Practice Address - Street 2:STE 1
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001
Practice Address - Country:US
Practice Address - Phone:860-678-1800
Practice Address - Fax:508-829-5367
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0436662086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001436668Medicaid
I50314Medicare UPIN
CT240000188Medicare PIN