Provider Demographics
NPI:1518612779
Name:DEDEAR, COLBY
Entity Type:Individual
Prefix:
First Name:COLBY
Middle Name:
Last Name:DEDEAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 OAK FOREST RD
Mailing Address - Street 2:
Mailing Address - City:GOLIAD
Mailing Address - State:TX
Mailing Address - Zip Code:77963-3625
Mailing Address - Country:US
Mailing Address - Phone:361-218-2547
Mailing Address - Fax:
Practice Address - Street 1:2701 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901
Practice Address - Country:US
Practice Address - Phone:361-573-9181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXGMR00108708247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist