Provider Demographics
NPI:1609419001
Name:COLOMBINE, OLIVER
Entity Type:Individual
Prefix:MR
First Name:OLIVER
Middle Name:
Last Name:COLOMBINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 MISTY LAUREL CT
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-1791
Mailing Address - Country:US
Mailing Address - Phone:954-612-9544
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman