Provider Demographics
NPI:1558332015
Name:COLBERT, GREGORY H (DPM)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:H
Last Name:COLBERT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 W LAWRENCE AVE
Mailing Address - Street 2:PO BOX 735
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1442
Mailing Address - Country:US
Mailing Address - Phone:517-543-0505
Mailing Address - Fax:
Practice Address - Street 1:436 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1442
Practice Address - Country:US
Practice Address - Phone:517-543-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGC001416213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4706341Medicaid
MI5274840001Medicare NSC
MI5235204Medicare PIN
MI5235204Medicare ID - Type Unspecified
MI4706341Medicaid