Provider Demographics
NPI: | 1497884506 |
---|---|
Name: | COLVEN, ROY MITCHELL (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | ROY |
Middle Name: | MITCHELL |
Last Name: | COLVEN |
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: | 325 9TH AVE, BOX 359763, DERMATOLOGY SECTION |
Mailing Address - Street 2: | |
Mailing Address - City: | SEATTLE |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98104 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 206-744-4321 |
Mailing Address - Fax: | 206-744-8527 |
Practice Address - Street 1: | 325 9TH AVE, DERMATOLOGY SECTION |
Practice Address - Street 2: | |
Practice Address - City: | SEATTLE |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98115 |
Practice Address - Country: | US |
Practice Address - Phone: | 206-744-4321 |
Practice Address - Fax: | 206-744-8527 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-03-05 |
Last Update Date: | 2015-04-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | MD00026751 | 207N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | 070013111 | Other | RAIL ROAD MEDICARE |
WA | 8129579 | Medicaid | |
WA | 000107419 | Medicare ID - Type Unspecified | UW PHYSICIANS |
WA | 8129579 | Medicaid | |
WA | AB25269 | Medicare PIN |