Provider Demographics
NPI:1578562252
Name:COLLEY, JOHNNY M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:M
Last Name:COLLEY
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 1:51 DOGWOOD LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503
Mailing Address - Country:US
Mailing Address - Phone:903-701-0156
Mailing Address - Fax:903-793-7996
Practice Address - Street 1:1000 PINE ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501
Practice Address - Country:US
Practice Address - Phone:703-701-0156
Practice Address - Fax:903-793-7996
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3854207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX09743Medicaid
TX8D0882Medicare ID - Type Unspecified
C14649Medicare UPIN
TX09743Medicaid