Provider Demographics
NPI:1255002408
Name:FORD, COLBY TYLER (PHD)
Entity Type:Individual
Prefix:DR
First Name:COLBY
Middle Name:TYLER
Last Name:FORD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-5131
Mailing Address - Country:US
Mailing Address - Phone:828-773-8009
Mailing Address - Fax:
Practice Address - Street 1:2413 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5131
Practice Address - Country:US
Practice Address - Phone:828-773-8009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0000000000207SG0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular Genetics