Provider Demographics
NPI:1457462020
Name:COLVILLE, AMBER D (MD)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:D
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 1:1135 OCEAN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3421
Mailing Address - Country:US
Mailing Address - Phone:228-875-6695
Mailing Address - Fax:228-875-6696
Practice Address - Street 1:1135 OCEAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3421
Practice Address - Country:US
Practice Address - Phone:228-875-6695
Practice Address - Fax:228-875-6696
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00144953OtherMEDICARE RR
MS11397919OtherUNITED HEALTH CARE
MS7288627OtherAETNA
MS02107231Medicaid
MSP00144953OtherMEDICARE RR
MS11397919OtherUNITED HEALTH CARE