Provider Demographics
NPI:1558465849
Name:COLOM, WILLIAM A (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:COLOM
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 1:447 MONTAUK AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320
Mailing Address - Country:US
Mailing Address - Phone:860-447-1426
Mailing Address - Fax:860-447-0348
Practice Address - Street 1:447 MONTAUK AVENUE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-447-1426
Practice Address - Fax:860-447-0348
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1177724Medicaid
CT110000800Medicare PIN
CT1177724Medicaid