Provider Demographics
NPI:1487656286
Name:COLBERT, JEFFREY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:COLBERT
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:PO BOX 3129
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3129
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:4644 LINCOLN BLVD
Practice Address - Street 2:SUITE 530
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6313
Practice Address - Country:US
Practice Address - Phone:310-421-2111
Practice Address - Fax:310-822-4104
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46171207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA50311Medicare UPIN
CA1137090001Medicare NSC
CAG46171Medicare PIN
CAG46171OtherMEDICAL LICENSE
CAA50311Medicare UPIN