Provider Demographics
NPI:1598735391
Name:COLWELL, THEODORE W (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:W
Last Name:COLWELL
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:PO BOX 742941
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 ELM STREET
Practice Address - Street 2:STE 310
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-454-2035
Practice Address - Fax:208-454-1065
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD93712207V00000X
IDM-4462207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010003390OtherREGENCE BLUE SHIELD OF ID
ID003644200Medicaid
OR291948Medicaid
ID44628OtherBLUE CROSS OF IDAHO
IDD93712Medicare UPIN
ID1117188Medicare ID - Type Unspecified