Provider Demographics
NPI:1568475275
Name:COLVERT, JAMES ROBERT JR (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:COLVERT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:800 SHARE DR
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717-3618
Mailing Address - Country:US
Mailing Address - Phone:580-430-3366
Mailing Address - Fax:580-430-3365
Practice Address - Street 1:800 SHARE DR
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717-3618
Practice Address - Country:US
Practice Address - Phone:580-430-3366
Practice Address - Fax:580-430-3365
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11570207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C94789Medicare UPIN