Provider Demographics
NPI:1477551273
Name:COLON, ATHOS GABRIEL (MD)
Entity Type:Individual
Prefix:
First Name:ATHOS
Middle Name:GABRIEL
Last Name:COLON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ATHOS
Other - Middle Name:GABRIEL
Other - Last Name:COLON - LEDEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4626 94TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-5016
Mailing Address - Country:US
Mailing Address - Phone:806-791-5913
Mailing Address - Fax:806-791-5937
Practice Address - Street 1:3602 23RD ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1326
Practice Address - Country:US
Practice Address - Phone:806-368-8723
Practice Address - Fax:806-368-8724
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK06902080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ1658Medicaid
TX137294812Medicaid
NMJ1658Medicaid