Provider Demographics
NPI:1538104344
Name:COLVIN, MEDA K (MD)
Entity Type:Individual
Prefix:
First Name:MEDA
Middle Name:K
Last Name:COLVIN
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 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:STE S-750
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072
Mailing Address - Country:US
Mailing Address - Phone:504-340-6976
Mailing Address - Fax:504-349-6786
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:STE S-750
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-340-6976
Practice Address - Fax:504-349-6786
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019520208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1976938Medicaid
LA1976938Medicaid
LA5R646Medicare ID - Type Unspecified