Provider Demographics
NPI:1255331906
Name:COLBURN, KENNETH LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:COLBURN
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 1:4120 BRADFORD HICKS DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:38570-2213
Mailing Address - Country:US
Mailing Address - Phone:931-823-5603
Mailing Address - Fax:931-403-0574
Practice Address - Street 1:4120 BRADFORD HICKS DR
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TN
Practice Address - Zip Code:38570-2213
Practice Address - Country:US
Practice Address - Phone:931-823-5603
Practice Address - Fax:931-403-0574
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21497207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3060384Medicaid
TN3060384Medicaid
C45767Medicare UPIN